Cdip

Front 1

7 Criteria for quality documentation

Back 1

1. Legible - clear enough to be read and deciphered

2. Reliable - trustworthy, safe, able to be repeated

3. Precise - accurate, exact, strictly defined (detailed)

4. Complete - maximum content, thorough covering all concerns

5. Clear - not vague

6. Consistent - not contradictory

7. Timely

Front 2

OIG minimum documentation compliance for a health record

Back 2

1. Complete and legible

2. Past and present diagnosis

3. Health risks factors identified

4. Rationale for diagnostic tests and ancillary services

5. Documented patient response and changes in treatment, revisions in diagnosis

6. Documentation for each encounter includes reason for the encounter, relevant history, exam findings, diagnostic test results, clinical impression, diagnosis and plan of care

Front 3

Outpatient documentation issues

Back 3

1. Lack of clarity

2. Medical necessity not met

3. limited supply of outpatient coders and usually they have the least amount of experience

Front 4

Definition - Principal Diagnosis

Back 4

Inpatient - condition, after study, that is determined to have caused the admission

Front 5

Definition - Secondary Diagnosis

Back 5

Inpatient - All other conditions clinically evaluated, treated and tested during the stay or responsible for increasing the LOS or using other resources

Front 6

DRG system

Back 6

• DRG = Diagnosis Related Group
• MS-DRG = Medicare Severity DRG and was created in 2008 - used for inpatient hospital stays
• AP-DRG = All patient DRG, some states use for Medicaid reimbursement, created by 3M
  • APR- DRG = All patient refined DRG, Created by 3M, used to analyze some portion of data for Medicare Quality Indicators

Front 7

Definition - POA

Back 7

Is the condition Present on Admission, started in 2007, used to help determine severity and intensity of resources needed for the hospital admission

If the Diagnosis is not POA, it is considered a quality concern for the hospital and is not considered in severity and intensity for payment/DRG selection

Front 8

FY 2015 for Coding

Back 8

October 2014 to September 2015

Front 9

Cooperating Parties for ICD-9

Back 9

1. CMS - procedure side

2. NCHS National Center for Health Statistics- Diagnosis

3. AHA American Hospital Association - coding clinic and guidelines

4. AHIMA - education

Front 10

Definition UHDDS

Back 10

Uniform Hospital Discharge Data Set - requires that all significant procedures be reported

significant = Is surgical in nature, carries a procedural risk, carries and anesthesia risk, requires specialized training

Front 11

Definition Principal Procedure

Back 11

That which was performed for definitive treatment rather than for diagnostic or exploratory purposes or for treatment of a complication.

Front 12

Cancelled Procedure Coding

Back 12

1. If a cavity or space was entered, assign a code describing the exploratory procedure for that site

2. If an incision was made, assign a code describing the incision for that site

3. If a closed fracture reduction was attempted and aborted, no procedure code is assigned (use V64) - a failed procedure is a completed procedure

4. If a procedure is cancelled before it begins, no procedure code is assigned

4. If a procedure

Front 13

Incomplete Procedure Coding

Back 13

1. When a cavity or space is entered, code exploration of the site

2. When the endoscopic approach is used, but the definitive procedure could not be carried out, code the endoscopy only

3. When only an incision is made, code the site of the incision

4. When the procedure does not involve an incision, no procedure code is assigned

Front 14

MS-DRG represent/goals

Back 14

• Goal of the system is to significantly improve Medicare's ability to recognize severity of illness
  • represent an inpatient classification system designed to categorize patients who are medically related with respect to diagnosis and treatment and who are statistically similar in their lengths of stay

Front 15

MS-DRG formula (how to calculate payment)

Back 15

DRG Relative weight (same for everyone nationwide)

Hospital Base rate (varies by hospital)

DRG RW * Base rate = hospital payment

Front 16

Items impacting MS-DRG assignment

Back 16

• Principal and Secondary Diagnosis
• Surgical procedures
• Discharge disposition/status (where did they go home to)
  • Presence of MCC (Major complication/co-morbidity) or CC (complication/co-morbidity)

Front 17

CPT Code

Back 17

• Developed by AMA (American Medical Association)
• Updated annually on January 1
  • Does not impact DRG assignment

Front 18

What are HCPCS Codes

Back 18

Level 1 are CPT codes

Level 2 are local codes, drugs, DME, etc and maintained by CMS

Front 19

Who are users of Health Information

Back 19

• Patients
• Physicians
• Insurers
• Regulatory Agencies
  • Research

Front 20

Steps in the Communication Process

Back 20

Sender

Message

Medium (How sent)

Receiver

Front 21

CDI training program objectives

Back 21

• Adequately prepare CDI professional to participate in improving inpatient (outpatient) clinical documentation
  • To understand the impact of clinical documentation on severity, mortality, and morbidity
• To understand the relationship between CDI and case mix

Front 22

AHIMA's role as a participating party

Back 22

American Health Information Management Association - education and advocacy

Front 23

Who sets the Standards

Back 23

ICD - International Classification of Diseases

WHO - World Health Organization

NCHS - National Center for Health Statistics

Front 24

Cooperating Parties

Back 24

AHA - American Hospital Association

AHIMA - American Health Information Mgmt Assoc.

NCHS - National Center for Health Statistics

CMS - Cetner for Medicare and Medicaid Services

Front 25

AHIMA's role as cooperating party

Back 25

Education

Front 26

AHA's role as cooperating party

Back 26

Clearinghouse for issues related to ICD-9

Publishes Coding Clinics

Front 27

NCHS's role as cooperating party

Back 27

Diagnosis side of ICD

Front 28

CMS's role as cooperating party

Back 28

Regulations regarding quality and reimbursement

Front 29

OIG

Back 29

Office of Inspector General - work plan each year showing focus areas (target area)

Developed in 1976 and is part of HHS

Front 30

AHRQ current focus areas

Back 30

Agency for Healthcare Research and Quality

1. Prevention Quality Indicators

2. Inpatient Quality Indicators

3. Patient Safety Indicators

4. Pediatric Quality Indicators

Front 31

IPPS quality measures

Back 31

mandatory data submission

acute myocardial infarction (AMI)

heart failure (HF)

Pneumonia (PN)

Surgical care improvement project (SCIP)

30 day mortality rates for AMI, HF and PN

Front 32

Outpatient OPPS Measures

Back 32

Created by 2006 Tax Relief and Health Care Act, contains 119 measures

Front 33

NPSG

Back 33

National Patient Safety Goals - Joint Commission 15 measures

Front 34

QI process

Back 34

This is a circular process

Identify performance measures

Start measuring

Look at data - analyze

Identify improvement opportunities

Continually Monitor

Front 35

Other names for Performance Improvement (PI)

Back 35

CQI - Continuous quality improvement

TCM - total quality management

Front 36

What is a Mission Statement

Back 36

Short description of the general purpose of an organization or group

Explains why the organization exists

Usually includes a broad definition of the services provided

Front 37

What is a Vision Statement

Back 37

Short description of the organization's future ideal state. Is idealistic and futuristic

Front 38

What is a Value Statement

Back 38

Supports the behavior of the organization

Promotes social and cultural beliefs

Ethics statement

Front 39

4 stages to team building

Back 39

1. Forming - people start to work together and make an effort to get to know their colleagues

2. Storming - people start to push against the boundaries established in the last phase, many teams fail at this stage; question the worth of the team's goals

3. Norming - people being to resolve differences, appreciate strengths of other team members

4. Performing - the team is work on the goal

Front 40

FOIA

Back 40

Freedom of Information Act - first privacy law in US; applies to federal agencies