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

Front 41

Privacy under HIPAA

Back 41

1. Sets a federal "floor" for privacy

2. Limits how information can be used or disclosed

3. Gives rights to individuals

4. Civil penalties

5. Enforced by the Office of Civil Rights (OCR)

6. Patients can request amendment to information (accounting of disclosures)

Front 42

Security under HIPAA

Back 42

1. Who has access to information

2. national standard for electronic information

3. Administrative, physical and technical safeguards

4. Security measures when disclosing information

Front 43

Administrative, Physical and Technical Safeguards

Under HIPAA

Back 43

Admin - identify/analyze risks; staff training; limiting access; contingency planning

Physical - facility access controls; workstation security; workstation policies

Technical - access controls to PHI; audit controls; integrity controls; transmission security measures

Front 44

HIPAA breach definition

Back 44

An impermissible use or disclosure under the Privacy Rule that compromises the security or privacy of PHI

Front 45

Fraud and Abuse Definition

Back 45

Fraud - Intentional deception or misrepresentation that an individual knows to be false or does not believe to be true and makes, knowing that deception could result in some unauthorized benefit to himself or other person

Abuse - activity where someone overuses or misuse service

Front 46

Fraud and Abuse Monitoring

Back 46

PPACA - Patient Protection and Affordable Care Act created new fraud tools and expanded definition of improper conduct

Title XI (11) of the Social Security Act - exclusion from the federal payer program if convicted of misconduct

Front 47

What are "red flags" for auditors (compliance)

Back 47

Repeated provider errors

Annual code updated (are the providers using the updates)

New Payer requirements (reimbursement changes)

Front 48

4 components of a compliance plan

Back 48

1. Policy and Procedure Development

2. Program Monitoring (validity of queries, working DRG assignments, missed query opportunities)

3. Auditing

4. Follow up education

Front 49

What information should be included on a query?

Back 49

Patient Name

Admission date/date of service

Health record number

Account number

Date of query

Name/contact info for response to query

Statement of the issue (open ended, multiple choice) should not be yes/no

Front 50

What information should be included in the Statement of the Issue in a query?

Back 50

Should be written as a question

- clinical indicators from the chart

- as the provider to make a clinical interpretation of the facts in the chart

-query format should not sound presumptive, directing, prodding, proving or as though the provider is being led to a diagnosis

Front 51

New information in a query

Back 51

Introduction of new information not previously documented is inappropriate

can say patient is on XYZ medication, is there a diagnosis

dr. says fracture, radiology report gives more details on location, can query the doctor a yes/no question on location

Front 52

Yes/No Queries

Back 52

should be avoided where possible

POA is the exception

Front 53

Multiple choice queries

Back 53

Make as open ended as possible

-Clinically relevant/reasonable choices should be listed

- Also need to include "other"; "Unable to determine"; and "clinically irrelevant"

-Be sure to give a line (place) for the doctor to specify information in the "other" answer

Front 54

Is a query needed?

Back 54

Does the patient's record have:

-conflicting information

-ambiguous information

-incomplete information

-clinically relevant information

-regards any significant reportable condition or procedure,

if yes, query

Front 55

Indicators when a query is needed

Back 55

- record not legible

-record not complete, missing test results, missing a progress note, etc

- clarity issues- diagnosis documented without documentation of cause or suspected cause

- can't determine POA

- consistency (differing information between providers)

Front 56

Timing of a query

Back 56

Concurrent - CDI is usually concurrent

Retrospective - coding is usually completed here

- post bill - most often completed after an audit (external or internal)

Front 57

When not to query

Back 57

-when the benefit is strictly for reimbursement

- no clinical evident to support a query

- when facility guidelines state not to query

- clinically insignificant findings or irrelevant information shouldn't result in a query

Front 58

examples of key metrics for CDI program

Back 58

Top DRG

Conditions most often queried

Record review rate

Physician query rate

Physician response rate

validation rate - are the right questions being asked

Front 59

Examples of CDI program goals

Back 59

effective and efficient

developed specifically by the organization

guided by key metrics (Indicators)

clinical documentation captures SOI and ROM

clarify missing/incomplete/conflicting documentation

supports accurate diagnosis

promote patient safety through a complete record

Front 60

4 types of categorical data

Back 60

1. Nominal - values fall into unordered categories (true/false; male/female)

2. Ordinal - values are ordered categories or are ranked (0-10 scale)

3. Ranked - arranged highest to lowest and then assigned numbers that correspond to each observation's place in the sequence (top 4 leading causes of death)

4. Interval - units of equal size (IQ scores)

Front 61

2 types of numerical data

Back 61

1. discrete - finite number (How many in household, the number of new AIDS cases)

2. Continuous - measurable quantities (blood pressure, serum cholesterol)

Front 62

ways to display data

Back 62

Table - columns/rows used for all types of data; summarizing a set of observations

Bar Graph - frequency distribution for nominal or ordinal data

Histograms - frequency distributions for continuous (interval or ratio data)

Line Graph relationship between continuous quantities (patterns/trends)

Pie chart - components as part of a whole

Front 63

Recommended data capture items

Back 63

discharge by service

discharge by DRG

discharge by Major Diagnostic Category (MDC)

Case Mix index

Complication rate

severity level

Medicare quality indicators

Front 64

how to calculate denial rate

Back 64

number of claims denied divided by the number of claims submitted

Front 65

tracking queries

Back 65

query rate = number of queries divided by number of records reviewed

track by physician, response rate, validation rate

Front 66

What is the definition of Case Mix Index CMI

Back 66

the average DRG relative weight for inpatient cases, is an indicator of average reimbursement per patient

Front 67

What might impact a change in the Case Mix Index

Back 67

seasonal variations (flu, pneumonia)

medical and surgical mix

physician staffing changes

coding competency

SOI among the patient population

Front 68

PPS - prospective payment system concepts

Back 68

1972

Establish payment rates in advance and apply as "fixed"

Rates not automatically determined by the hospital's past or current cost

Payment is payment in full

Hospital retains profit or loss

Front 69

PPS inpatient includes?

Back 69

Acute care hospital

excludes: psych units; long term care unit; rehab units

Front 70

PPS types (examples)

Back 70

IPPS - Acute inpatient - DRG

OPPS Hospital outpatient APC

HH Home Health OASIS

SNF Skilled Nursing Facility MDS

IRF Inpatient Rehab facility