Five Pillars for Building a Successful CDI Program in Emergency

Five Pillars for Building a Successful CDI Program in Emergency Services Amber Sterling, RN, BSN, CCDS Director, CDI Auditing Services TrustHCS Springfield, MO 1

Learning Objectives At the completion of this educational activity, the learner will be able to: – Describe the importance of implementing a CDI program at the point of entry in the ED and how this affects the overall accuracy of documentation and coding programs. – Define the five strategies to build a successful CDI program within emergency services including tips for a smooth transition and faster implementation. – Identify possible challenges and triggers to be aware of and how to combat these obstacles for a seamless program. – Collaborate on best practices for starting a successful CDI program for your ED. 2

Importance of CDI at Point of Entry Getting CDI specialists involved at the point of entry in the emergency department (ED) provides important benefits to downstream documentation and coding accuracy. The entire CDI effort for each case becomes more effective when a successful CDI program for emergency services is deployed. 3

Coding Challenges in the ER Does documentation – Support the most appropriate visit level? – Supports the billable services? – Accurately report staff present for care provided? – Accurately report the amount of time staff spend with critical patients? 6

Supporting the Most Appropriate Visit Level ER Facility Visit Levels: Evaluation and Management of CPT Codes 1. Self-limited or minor (99281): a problem that runs a definite and prescribed course, is transient, and is not likely to permanently alter the patient’s health status or has a good prognosis with management/compliance. 2. Low severity (99282): a problem in which the risk of morbidity without treatment is low, there is little to no risk of mortality without treatment, and full recovery without functional impairment is expected. 3. Moderate severity (99283): a problem in which the risk of morbidity without treatment is moderate, there is moderate risk of mortality without treatment, or there is an uncertain prognosis or increased probability of prolonged functional impairment. 4. High severity, requires urgent evaluation by the physician but does not pose threat to life or physiologic function (99284): A problem in which the risk of morbidity (illness, disease) without treatment is high to extreme, there is a moderate to high risk of mortality (death) without treatment, or a high probability of severe, prolonged functional impairment. 5. High severity, poses an immediate significant threat to life or physiologic function (99285): A problem in which the risk of morbidity (i.e., illness, disease) without treatment is high to extreme, there is a moderate to high risk of mortality (death) without treatment, or a high probability of severe, prolonged functional impairment. (ACEP, 2001) 7

Documentation Challenges with Accurate Facility Visit Levels How does the documentation impact what facility visit level is coded? EXAMPLE: Blood draw from a PICC Nursing present in the room during a pelvic exam Clear documentation of a combative/intoxicated patient (security called, use of extra resources, etc.). 8

Supporting the Billable Services Clinical Review Ensure that services provided have supporting documentation that corresponds to the clinical picture Detect missing elements within the documentation Act as a clinical resource for questions that the HIM Specialist may have when assigning codes and visit levels 9

Accurately Report Staff Present for Care Provided Billing Difference Between ER and Other Areas: – 1:1 time of physicians and nurses Timeframe of patient time with nurses Obtaining documentation to support Observation vs Assessment: – CDIS familiar with treatment and/or procedures according to disease process 10

Accurately Report the Amount of Time Staff Spend with Critical Patients Critical care is defined as, “the direct delivery of medical care by a physician or provider to a critically ill or injured patient” (Scott, 2015). CMS only pays for critical care if at least 30 minutes of critical care services are provided and documented If the facility does not provide at least 30 minutes of critical care, visit is coded at a level 4 (CPT 99284) or 5 ED visit (CPT 99285) CDIS clinical knowledge regarding what disease processes and/or treatment would call for closer monitoring helps ensure time is questioned if it seems shorter or longer than expected 11

Benefits to Documentation Integrity for Inpatient Admissions from ER Emergency services documentation captures the severity of the patient at presentation ER provider documentation often differs from the documentation of the admitting physician – Fast pace of the ER and shift work for providers – Attending seeing the patient after the patient has received treatment 12

Benefits to Documentation Integrity for Inpatient Admissions from ER Example: Shock: 84 year old female patient presents with UTI, encephalopathy and hypovolemic shock due to dehydration from GI E. Coli infection. Patient given 5L IVF bolus in ED and decision made to admit for IV antibiotics and resolution of encephalopathy. Attending documents hypotension, resolved (does not carry documentation of shock through to H&P or progress notes). – Talk to the admitting provider as to why they did not carry the shock over – If there is a question about the diagnosis, coordinate a peer to peer conversation 13

Benefits to Documentation Integrity for Inpatient Admissions from ER Benefits for Medical Necessity – Timely query for the most accurate principal diagnosis – Ensure the documentation is consistent from the Emergency Department to the admission – Accurate GMLOS and status from the time of admission Know the criteria that is utilized by the facility – The most common medical necessity criteria used are InterQual and MCG – Access to the software used for screening 14

Benefits to Documentation Integrity for Inpatient Admissions from ER Impact on Readmissions Readmissions Reduction Program (HRRP) – Risk adjustment methodology endorsed by the National Quality Forum (NQF) – Includes adjustment for factors that are clinically relevant including certain patient demographic characteristics, comorbidities, and patient frailty – Importance of capturing CC and MCC 15

Benefits to Documentation Integrity for Inpatient Admissions from ER Readmissions Reduction Program (HRRP) – – – – – Heart Failure Acute Myocardial Infarction Pneumonia COPD THA/TKA 16

Benefits to Documentation Integrity for Inpatient Admissions from ER Hospital-Acquired Condition Reduction Program (HACRP) Section 3008 of the Patient Protection and Affordable Care Act (ACA) Provides an incentive for hospitals to reduce HACs Payments will be adjusted using risk-adjusted HAC quality measures Hospitals will have their payments reduced to 99% of what would otherwise have been paid for such discharges 17

Benefits to Documentation Integrity for Inpatient Admissions from ER FY 2017 HAC Reduction Program information for each hospital on Hospital Compare in December 2016: – – – – – Patient Safety Indicator (PSI) 90 Composite measure score Central Line-Associated Bloodstream Infection (CLABSI) Catheter Associated Urinary Tract Infection (CAUTI) Surgical Site Infection (SSI) Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia – Clostridium difficile Infection (CDI) measure 18

5 Pillars for a More Effective Program And Lessons Learned 19

5 Pillars for a More Effective Program 1. Start Early – Strategy for developing a starting point Internal and/or external audit of visit levels coded and billed Quality initiatives GMLOS outliers Readmission risks 21

5 Pillars for a More Effective Program 1. Start Early 2. Technology – Take Advantage of Technology Bed board Alert systems for Case Management, Quality, etc – Extends the value of the CDI program with minimal need to create hybrid positions 22

5 Pillars for a More Effective Program 1. Start Early 2. Technology 3. Collaborate – Case Management Correct status Correct LOC GMLOS Readmissions – Quality At risk quality measures – Nursing Education regarding documentation – Example: start and stop times on infusions – ER Providers One on one education to understand documentation requirements 23

5 Pillars for a More Effective Program 1. 2. 3. 4. Start Early Technology Collaborate Reporting Structure – Ensure physician, ER Department and Case Management leadership understand the role and are on board – Clear delineation of role is paramount to success 24

5 Pillars for a More Effective Program 1. 2. 3. 4. 5. Start Early Technology Collaborate Reporting Structure Prepare for Pushback – Common Challenges Encountered – Selling Your Program to Executives – Preparing Physicians 25

Collaboration and Defining Roles And Lessons Learned 26

Collaboration and Defining Roles: Case Managers Alerting Case Management for admission status or readmissions – Possible evaluation in ER to determine if patient can be admitted to a lower level of care (ex. SNF) – Notifying CM when an IP order is written but patient does not meet Inpatient admission criteria – Reconciliation of principal diagnosis with medical necessity and coding – Early awareness to GMLOS associated with DRG to help pace the discharge planning 28

Collaboration and Defining Roles: Physicians (ED, Hospitalists, & Attending) Educate providers on – The necessity of consistent documentation – Documenting the necessity of interventions used to treat/evaluate the patient – The necessity of accurately reporting critical care time spent treating/evaluating patient If attending provider examines patient in the ER, discuss potential principal and secondary diagnoses Coordinate peer to peer conversations 29

Summary Create a Focus on CDI at the Point of Entry REMEMBER: 5 Pillars for a More Effective Program – – – – – Start Early Technology Collaborate Reporting Structure Prepare for Pushback Collaborate and Define Roles 30

References American College of Emergency Physicians. ED Facility Level Coding Guidelines. Copyright 2011. Retrieved from https://www.acep.org/content.aspx?id 30428 Center for Medicare & Medicaid Services. Hospital-Acquired Condition Reduction Program (HACRP). Retrieved from https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Acut eInpatientPPS/HAC-Reduction-Program.html on 2/01/20017 . Center for Medicare & Medicaid Services. Readmissions Reduciton Program (HHRP). Retrieved from https://www.cms.gov/Medicare/Medicare-Fee-for-Service Payment/ AcuteInpatientPPS/Readmissions-Reduction-Program.html on 2/01/2017. Scott, N. JustCoding’s Emergency Department Coding Handbook. Retrieved from https://hcmarketplace.com/index.php/aitdownloadablefiles/download/ai tfile/aitfile id/1701.pdf 31

Thank you. Questions? [email protected] 32