Challenges in Clinical Challenges in Clinical Documentation:Documentation:

Stories from the Front LineStories from the Front LineJon Elion MD, FACC

Associate Professor of Medicine, Brown UniversityPresident and CEO, ChartWise Medical Systems

jElion@chartwisemed.com

Jon Elion MD, FACCJon Elion MD, FACC1. Medical Computing: Since 1969

2. Clinical: Duke-trained cardiologist

3. Academic: Assoc Prof at Brown

4. Administration: Hospital Boards,Foundation and Finance Committees

5. Commercial: Medical software since1994. Now President and CEOof ChartWise Medical Systems(Computer-Assisted ClinicalDocumentation Improvement).

Five Things to Know about Jon…

Jon Elion, M.D., FACC

Clinical DocumentationClinical DocumentationClinical Documentation should be a

thorough record of the diagnos(es) made, symptoms observed, treatment procedure planned and executed, the care provided,

the outcome of treatment and clinical assessment of the entire treatment

process.**From “Guidelines for Improvement in Clinical Documentation”

by Tom Bilmore; http://EzineArticles/5034354

Clinical Documentation Clinical Documentation ImprovementImprovement

…improve the accuracy, specificity and completeness of clinical documentation through education, assessment, review,

communication, clarification, querying and analysis of clinical documentation patterns…

*

*From Catholic HealthCare West Clinical Documentation Improvement Program

Clinical Documentation SpecialistClinical Documentation Specialist…Assess the accuracy, specificity and

completeness of physician clinical documentation and to identify if clinical findings suggest the presence of other

conditions that are not explicitly documented…*

*From Catholic HealthCare West Clinical Documentation Improvement Program

Patient admitted for bowel surgery

““Heart Heart Failure”Failure”““Heart Heart

Failure”Failure”

““Systolic Systolic Heart Heart

Failure”Failure”

““Systolic Systolic Heart Heart

Failure”Failure”

““Acute Acute Systolic Systolic Heart Heart

Failure”Failure”

““Acute Acute Systolic Systolic Heart Heart

Failure”Failure”

Diuresed, patient

does well

Diuresed, patient

does wellPost-op, Congestive Heart Failure is detected,cardiologistis consulted

Background: One ExampleBackground: One ExampleBackground: One ExampleBackground: One ExampleIf note says:

It’s All About Quality…It’s All About Quality…

If you pursue reimbursement, you will miss the High Quality Medical Record

… but ...

If you pursue the High Quality Medical Record, the proper reimbursement will follow.

……Not Just About ReimbursementNot Just About ReimbursementComplete and accurate coded data is essential for:

Improved quality of patient careDecision-making on healthcare policiesOptimizing resource utilizationIdentifying and reducing medical errorsClinical research, epidemiological studies

Physician documentation is thecornerstone of accurate coding

Don’t fall into this trap!Don’t fall into this trap!

What Would You Code?What Would You Code? A 92 year-old woman is admitted to the Coronary Care Unit

following a fall at home. She complains of chest and hip pain

She has an elevated troponin, and her ECG shows new inferior ST elevation.

The orthopedic resident sees the patient, reviews the x-rays of the pelvis and hip. His note says “The ice cream fell off the cone”

What Would You Code?What Would You Code?

Slipped Capital Femoral EpiphysisSlipped Capital Femoral Epiphysis

Fracture of neck of femur 820: 820 Fracture of neck of femur 820.0 Transcervical fracture closed 820.00 … intracapsular section neck of femur, unspec. 820.01 … epiphysis (separation) upper neck of femur 820.02 … of midcervical section of neck of femur 820.03 … of base of neck of femur 820.09 … other transcervical of neck of femur

What Would You Code?What Would You Code?

S72.02 Fracture of epiphysis (separation) (upper) of femur S72.021 Displaced fracture, right femur S72.022 Displaced fracture, left femur S72.022A Initial encounter closed fracture S72.022B Initial encounter open fracture I or II S72.022C Initial encounter open fracture IIIA, IIIB, or IIIC S72.022D Subsequent encounter closed fracture healing S72.022E Subsequent encounter open fracture I or II

with routine healing …

What Would You Code?What Would You Code?

Documentation:Documentation:Why Should We Care?Why Should We Care?

Documentation:Documentation:Why Should We Care?Why Should We Care?

THEY AREWATCHING YOU!

Documentation:Documentation:Why Should We Care?Why Should We Care?

• A patient with cholecystitis undergoes a cholecystectomy

• Post-op, the patient spikes a temperature with high WBC

• Abdomen tender, diffuse rebound, pulse 110, respirations 22

• KUB and abdominal CT unremarkable

• IV Cipro started, Infectious Disease consulted

• Patient improves, is discharged on post-op day 6 on oral Cipro

Documentation:Documentation:Why Should We Care?Why Should We Care?

Acute Cholecystitis + Laparoscopic Cholecystectomy$8,168, expected LOS 2.4 days

Adding Probable Acute Peritonitis and Sepsis$17,477, expected LOS 6.2 days

Documentation:Documentation:Why Should We Care?Why Should We Care?

October 21, 2013

United Healthcare dropping R.I. doctors fromMedicare Advantage network

What Would You Code?What Would You Code? One of the great mentalists of 1800s

A frenetic performance, culminatingin a “catalectic fit”

A note in his pocket stated hiscatatonic state was not death

After a fit at a performance in 1889he was promptly autopsied

His death certificate officially read “hysterocatalepsy”

Washington Irving Bishop 1855 – 1889

Psychogenic non-epileptic seizures are events superficially resembling an epileptic seizure, but without the characteristic electrical discharges associated with epilepsy

ICD9: 780.39 Other Convulsions

ICD9: 300.11 Conversion Disorder

ICD10: F44.5 Dissociative Convulsions

Death by Autopsy ???

Did they use ICD1 in 1889 ???

FYI: HFYI: Hysterocatalepsyysterocatalepsy

1853: The 1st International Statistical Congress: Resolution requesting the preparation of a uniform classification of causes of death

1891: The International Statistical Institute (successor to the International Statistical Congress), charged a committee with the preparation of a classification of causes of death

1893: The report of this committee was adopted by the International Statistical Institute

For all practical purposes, this was “ICD1” (but never called that)

Think ICD-10 is Taking a Long Time?Think ICD-10 is Taking a Long Time?

Near-Death by Autopsy?Near-Death by Autopsy? Best remembered for “Paget’s

Disease” of the bone

Considered as the founder ofscientific medical pathology

Developed septicemia after aself-inflicted injury during autopsy

Thereafter he claimed that he wasthe first person ever to survive the attention of 10 doctors

Sir James Paget 1814 – 1899

What’s Wrong with This Picture?What’s Wrong with This Picture?Hi Dr. Elion,Can I please get your permission to make this modification:

Patient D.M. (DOB: 10/7/1948) admitted 3/12/14. You billed 401.1 Benign Hypertension; however, documented in note is “Hypertensive Urgency.” There is a more specific diagnosis we could use instead of 401.1. Do you want to bill 402.10 Hypertensive Heart Disease Benign without Congestive Heart Failure in place of 401.1?

Thank you, WLClinical Coding Specialist, CPC-A, CEMC

My ReplyMy ReplyThere is no corresponding ICD9 code for “Hypertensive Urgency”. If signs of current or impending end-organ damage, then it is one of the variations of “malignant” hypertension. Without that, it is Essential Hypertension, 401.1.

In order the have 402.10 Hypertensive Heart Disease, there would need to be evidence that the heart was involved in the hypertension process. The echo done January 22, 2014 says:

“The left ventricle chamber size, wall thickness, and systolic function are within normal limits”

So the patient would not qualify for 402.10

What’s Wrong with This Picture?What’s Wrong with This Picture?

Due ToDue To

This patient is known to have severe Aortic Stenosis.

Her downhill slide is probably due to dietary

indiscretion (she does not follow her diet). She is

symptomatically much improved after initial diuresis.

Her clinical picture is consistent with acute-on-

chronic systolic CHF due to Aortic Stenosis.

Query for ClarificationQuery for Clarification Query physicians for clarification and additional

documentation when there is conflicting, incomplete, or ambiguous information in the record

Do not query: when there is no supporting clinical information

for gram-negative pneumonia on every pneumonia case, regardless of clinical indicators

for sepsis when the clinical indicators are only suggestive of UTI + fever + increased WBCs

When to QueryWhen to Query Legibility: Illegible handwritten notes, and cannot

determine the provider’s assessment

Completeness: For example, an abnormal test results without notation of the clinical significance

Clarity: For example, diagnosis noted without statement of a cause or suspected cause

Consistency: Disagreement between two or more providers about diagnosis

Precision: Clinical reports and clinical condition suggest a more specific diagnosis than is documented

Not Only HandwrittenNot Only HandwrittenNotes are Illegible!Notes are Illegible!

Transfer: x 3 reps min assist progressing to CG with RW

Ambulation: 50 feet with RW with supervision, increased plantarflexion and hip flexion resembling TDWB, …Daughter ed re stair pattern, RW ordered.

Assessment Plan … not able to attempt stairs 2 to c/o and increased HR. RW ordered and received … D/c will likely be postponed today. Continue POC as tolerated.

Doctors on StrikeDoctors on Strike

Assessment Plan1.high k- resolved- I am very worried about gi bleed- needs stolls- ? gi consult2.esrd- hd for wed3.avr- on hep> coumadine4.bradycardia- resolved 5.dm

pt follows diet and goes to dial- he has high k , dropped hb, abd pain>>?? gi bleed????

What Would You Query?What Would You Query?

Query on abnormal lab interpretation

Query for clarification of “avr”Query for clarification: what is it due to?

Query for completeness

Query for abnormal lab and for cause

Query for completeness, specificityThis doc needs to

learn about !!!

The Kwashiorkor StoryThe Kwashiorkor StoryResults from inadequate protein intake.

Early symptoms:•Fatigue•Irritability•Lethargy

Late symptoms:•Growth failure•Loss of muscle mass•Generalized edema•Decreased immunity•Large, protuberant belly

One Hospital’s Kwashiorkor One Hospital’s Kwashiorkor Around 250 beds in a small town, median home price

$250,000, average income $60,000

1,030 cases reported in Medicare patients (18.6%). $11,463 per patient

Next highest incidence in the state 172 patients (3.8%)

One patient (shown here) has nonotation in the chart about edemaor swelling, no nutrition consult

Adult Malnutrition:Adult Malnutrition:Two or More FindingsTwo or More Findings

Insufficient energy intake

Weight loss

Loss of muscle mass

Loss of subcutaneous fat

Localized or generalized fluid accumulation that may sometimes mask weight loss

Diminished functional status as measured by hand grip strength

Adult Malnutrition: DocumentationAdult Malnutrition: Documentation History and Clinical Diagnosis: Conditions that might be

associated with inflammation and nutritional disturbances Clinical Signs and Physical Examination: SIRS, fluid

accumulation, signs of weight gain or weight loss. Anthropometric Data: Height, weight and weight history,

skin folds, circumference, other body composition metrics. Laboratory Indicators: Low proteins related to morbidity

and mortality. Inflammation, negative nitrogen balance Dietary Data: A diet history or 24-hour dietary recall Functional Outcomes: Assessment of strength and physical

performance, along with other associated findings.

Adult Malnutrition: Jon’s TipsAdult Malnutrition: Jon’s Tips Be sure that there is a clinical sense of a potential

nutritional disturbance before proceeding any further! Verify that at least 2of the 6characteristics from the ASPEN

guidelines are present to further confirm the diagnosis Avoid temptation to query about malnutrition (or to code

for it) when the only basis is an abnormal lab result Use the 6-point template suggested by the ASPEN

guidelines to provide complete documentation Look for other conditions and diagnoses that may produce

or be associated with malnutrition Don’t confuse the need for nutrition for the presence of

malnutrition

EncephalopathyEncephalopathy Rapid involuntary eye movement Inability to swallow or speak Muscle twitching, atrophy, weakness and tremor Memory loss, loss of cognitive ability Personality changes Inability to concentrate Loss of consciousness Dementia, seizures, lethargy

… … and at One Hospitaland at One Hospital

36% incidence in elderly Medicare patients at one hospitals

Other hospitals in the state reported encephalopathy in 3.6% of that population

A hospital could earn $7,000 per case for treating the condition as a complication

Not all Altered Mental Status is encephalopathy

Some consultants emphasize pursuing this diagnosis as an apparently easy way to increase revenues

Develop clear criteria for the diagnosis at your hospital

Anticipate close scrutiny from auditors

Beware!Beware!

First Document the Cause of AMSFirst Document the Cause of AMS Neurodegenerative diseases:

– Alzheimer’s disease (delusional, depressed, or psychotic)– Lewy body dementia (associated with Parkinson’s disease)

Psychiatric illnesses:– Mood disorders (unipolar depression or bipolar disorder 1 & 2)– Schizophrenia (specified as to the type)– Chemical dependencies, including drug withdrawal syndrome

AMS caused by a focal structural problem with the brain; seizure, concussion, stroke, transient ischemic attack, or tumor.

AMS caused by global dysfunction of the brain (encephalopathy!); toxic, septic, metabolic, hypertensive, or hepatic.

CDI: It’s Front Page NewsCDI: It’s Front Page News

If you have a high incidence of Kwashiorkor

If your CDI consultant promised in writing to increase revenues

If the first hour of your first day of training is all about encephalopathy

If you have an high incidence of malignant hypertension

If you are told:– Find an MCC then move on– Query for reimbursement or SOI

You May Be Headed forYou May Be Headed forthe Front Page…the Front Page…

A Few Helpful ReferencesA Few Helpful References Consensus Statement of the Academy of Nutrition and

Dietetics/American Society for Parenteral and Enteral Nutrition: Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition)J Acad Nutr Diet. 2012;112:730-738.www.wvda.org/meeting2012/Malnutrition.pdf

Cut Through the Confusion of Altered Mental Status by Brian Murphy. Association of Clinical Documentation Specialists, June 2009.www.hcpro.com/content/235239.pdf

Clinical Documentation Intelligence: www.chartwisemed.com