Documentation Impact and the

Physician Advisor
Timothy N. Brundage MD, CCDS
Certified Clinical Documentation Specialist
[email protected]
 Who Governs Our Coding Language?
▪ There are four designated entities who control our coding language

▪ These entities are the gate keeper for how words documented in the

medical record translate to medical codes and which diagnoses are

recognized in the coded record.

2
 4 Cooperating Parties
▪ CDC – responsible for diagnoses (the government)
▪ CMS – responsible for inpatient procedures (the government)
▪ American Hospital Association – responsible for interpreting ICD-10
o Through Coding Clinic
▪ American Health Information Management Association (AHIMA) –
o Provides input from the coding community

▪ Who is missing?
3
 Coding Clinic
▪ Quarterly newsletter published by the American Hospital Association

▪ Coding Clinic
▪ American Hospital Association (AHA)
▪ American Health Information Management Association (AHIMA)
▪ Centers for Disease Control and Prevention (CDC)
▪ Centers for Medicare and Medicaid Services (CMS)

▪ The Editorial Advisory Board consists of an expert panel of physicians

representing the American Medical Association, the American College of
Surgeons, the American Academy of Pediatrics and the American College of
Physicians, as well as coding professionals representing healthcare facilities.

http://www.ahacentraloffice.org/aboutus/what-is-icd-10.shtml 4
A Few Concepts

5
 Support Hospital Quality Reporting
through Clinical Documentation Integrity

6
Pay For Performance
 Present On Admission (POA)
▪ Present on admission is defined as present at the time the order for
inpatient admission occurs

o Conditions that develop during an outpatient encounter are

considered as present on admission

• Emergency department

• Observation

• Outpatient surgery
8
 Present On Admission (POA)
▪ Principal Diagnosis
o Must be present on admission – POA
▪ CMS and Premier (Care Science – QualityAdvisor) codes must be POA
to risk adjust mortality calculation
Indicator POA
Y Yes
N No
U Unspecified Designated NO
W Clinically cannot determine Designated YES

9
 Uncertain Diagnoses
▪ If the diagnosis documented at the time of discharge is qualified as

“probable”, “suspected”, “likely”, “questionable”, “possible”, or “still

to be ruled out”, or other similar terms indicating uncertainty, code

the condition as if it existed or was established.

10
 2 Midnight Rule
▪ On July 1, 2015, CMS released the updates to the “Two Midnight” rule.
▪ CMS emphasis on physician’s medical judgment
▪ Physician or other practitioner must decide whether to admit as inpatient
or treat as outpatient
▪ CMS observed a higher frequency of extended observation services
▪ Inpatient admissions will generally be payable under Part A if the admitting
practitioner expected the patient to require a hospital stay that crossed
two midnights and the medical record supports that reasonable
expectation
▪ All treatment decisions for beneficiaries were based on the medical
judgment of physicians
▪ CMS sought to respect the judgment of physicians
11
 IPPS Ruling – 2 Midnights Rule
▪ Inpatient Status

1. Inpatient Order**

2. Expectation of hospitalization crossing “2 Midnights” of time

3. Medical Necessity (what is that?)

12
 Medical Necessity
▪ “…in order for payment to be provided under Medicare Part A, the care

must be reasonable and necessary.”

▪ “The factors that lead a physician to admit a particular beneficiary based

on the physician’s clinical expectation…must be clearly and completely

documented in the medical record.”

13
 Medical Necessity
Medical Necessity Buzz Words
Support Inpatient Status

▪ Acute
▪ Patient is immunocompromised
▪ Acute on chronic
▪ The CURB-65 Score is…
▪ Decompensated
▪ The Pneumonia Severity Index is. . .
▪ Exacerbation
▪ The TIMI or HEART Score is . . .
▪ Worsening
▪ The SOFA Score is . . .
▪ Failed outpatient treatment

14
Myocardial Infarction

15
 First Question:
What’s the Correct Status?

16
Medical Necessity – Should the patient be INPATIENT?

▪ Inpatient admissions will generally be payable under Part A if the admitting

practitioner expected the patient to require a hospital stay that crossed two
midnights and the medical record supports that reasonable expectation

▪ All treatment decisions for beneficiaries were based on the medical judgment of
physicians

▪ CMS sought to respect the judgment of physicians

17
 Medical Necessity

▪ The care must be reasonable and necessary

▪ Must be clearly and completely documented in the medical record

18
 Chest Pain isn’t simply Chest Pain
Documentation MS-DRG Title RW Example
Reimbursement
Angina pectoris due to 303 Atherosclerosis w/o MCC 0.6656 $4568
ASCAD
Pleurisy 195 Simple Pneumonia w/o CC 0.6868 $4714
Angina pectoris NOS 311 Angina Pectoris 0.6872 $4716
Non- 313 Chest Pain 0.7073 $4854
cardiac/musculoskeletal
pain
Pericarditis 316 Other Circ System Dx w/o CC 0.7513 $5156
Heartburn / GERD 392 Esophagitis, Gastroenteritis and Misc GI 0.7554 $5184
d/o w/o MCC
Pleuritic (not chest wall) 204 Respiratory Signs and Symptoms 0.7676 $5268
pain
Biliary colic 446 Disorder of Biliary Tract w/o CC/MCC 0.7950 $5456
Costochondritis or rib 206 Other Resp Dx w/o CC/MCC 0.8635 $5927
fracture
19
Thoracic radiculopathy 552 Medical Back d/o w/o MCC 0.9010 $6184
 Fourth Universal Definition of Acute Myocardial Infarction 2018
▪ Myocardial infarction (MI) is acute myocardial injury detected by abnormal
cardiac biomarkers in the setting of evidence of acute myocardial ischemia
o Detection of a rise and/or fall of troponin with at least one value above the
99th percentile upper reference limit (URL) and with at least one of the
following:
• Symptoms of acute ischemia
• New ischemic EKG changes
• Development of pathological Q waves
• Imaging evidence of new loss of viable myocardium or new regional wall
motion abnormality consistent with ischemia
• Identification of an intracoronary thrombus by angiography or autopsy
20
 Fourth Universal Definition of Acute Myocardial Infarction 2018
▪ Acute myocardial injury
o 20% rise or fall of cardiac troponin over time

▪ Chronic myocardial injury

o <20% rise or fall of cardiac troponin over time
• CKD
• Structural Heart Disease

21
 Clinical Myocardial Ischemia
Symptoms
▪ Angina (chest pain, jaw pain, left shoulder/arm pain)
▪ Angina equivalents (SOB, fatigue)
▪ Syncope (often due to arrhythmia)
▪ Flash pulmonary edema (not gradual decompensation of chronic hear
t failure)
▪ Palpitations / Cardiac arrest
▪ “OR EVEN WITHOUT SYMPTOMS”
https://www.acc.org/latest-in-cardiology/articles/2018/11/16/09/06/fourth-universal-definition-of-mi
22
 Type 1 MI
▪ Atherothrombotic coronary artery disease (CAD) and usually
precipitated by atherosclerotic plaque disruption (rupture or erosion)
is designated as a type 1 MI

https://www.acc.org/latest-in-cardiology/articles/2018/11/16/09/06/fourth-universal-definition-of-mi 23
 NSTEMI is a Type 1?
Let the controversy begin!
Taken directly from the 4th Universal Definition

▪ New ST-segment elevations in two contiguous leads or new bundle branch

blocks with ischaemic repolarization as an ST-elevation MI (STEMI)

▪ In contrast, patients without ST segment elevation at presentation are

usually designated non-ST-elevation MI (NSTEMI)

https://www.acc.org/latest-in-cardiology/articles/2018/11/16/09/06/fourth-universal-definition-of-mi
24
 MI type 2
Detection of a rise and/or fall of troponin with at least one value above
the 99th percentile upper reference limit (URL) and evidence of an
imbalance between myocardial oxygen supply and demand unrelated
to CAD requiring at least one of the following:
• Symptoms of acute ischemia
• New ischemic EKG changes
• Development of pathological Q waves
• Imaging evidence of new loss of viable myocardium or new regional wall motion
abnormality consistent with ischemia
• Identification of an intracoronary thrombus by angiography or autopsy
▪ MI type 2 has a new code as of October 2017
o MI due to Demand Ischemia
o MI due to Ischemic Imbalance
25
 MI type 2
▪ The pathophysiological mechanism leading to ischaemic myocardial
injury in the context of a mismatch between oxygen supply and
demand has been classified as type 2 MI
▪ By definition, acute atherothrombotic plaque disruption is not a
feature of type 2 MI

26
 MI type 2
Causes
▪ Fixed coronary atherosclerosis
▪ Coronary spasm
▪ Coronary embolism
▪ Coronary artery dissection
▪ Sustained tachyarrhythmia
▪ Severe hypertension / LV hypertrophy
▪ Severe Bradyarrhythmia
▪ Respiratory failure
▪ Severe anemia
▪ Hypotension / Shock
27
 Ok, what is “NSTEMI Type 2”?
Depends on who you ask
▪ Kennedy/Goyal (ACC)
o NSTEMI type 2 is conflicting documentation because all NSTEMI are
type 1
o Remember the ACC is physician opinion which carries limited weight
with the 4 cooperating parties
▪ Huff/Huff
o NSTEMI encompasses all MI that do not raise the ST segments

▪ Coding NSTEMI type 2 codes to MI type 2 (I21.A1) -- Phew!

https://www.acc.org/latest-in-cardiology/articles/2018/11/16/09/06/fourth-universal-definition-of-mi
28
 4 Cooperating Parties
▪ CDC – responsible for diagnoses (the government)
▪ CMS – responsible for inpatient procedures (the government)
▪ American Hospital Association – responsible for interpreting ICD-10
o Through Coding Clinic
▪ American Health Information Management Association (AHIMA) –
o Provides input from the coding community

Do you see the American College of Cardiology on that list?

29
 “NSTEMI Type 2”
Coding Clinic, Q4 2017, page 12 “Types of Acute Myocardial Infarction”:

Question: How should a type 2 NSTEMI due to demand ischemia be

coded?
Answer: Assign code I21.A1, Myocardial infarction type 2. Do not assign
code I24.8, Other forms of acute ischemic heart disease for the demand
ischemia. Code also the underlying cause, if known. According to the ICD-10-
CM Official Guidelines for Coding and Reporting, “When a type 2 AMI code is
described as NSTEMI or STEMI, only assign code I21.A1. Codes I21.01-I21.4
should only be assigned for type 1 AMIs.”

https://www.acc.org/latest-in-cardiology/articles/2018/11/16/09/06/fourth-universal-definition-of-mi
30
 Physician Advisors
▪ Time to change HATS!

31
 AMI Mortality Cohort
Measure: 30-Day Risk-Standardized Mortality Rate Following AMI

• Principal diagnosis of AMI (Excluding Type 2 MI)

Dx Inclusion: •
•
Not transferred from another acute care facility
Age 65 or over
• Enrolled in Medicare FFS 12 months prior to index admission or VA beneficiary

• Discharged alive same day/next day, not transferred to another acute care
facility
• Enrolled in Medicare hospice program or used VA hospice services any time in
Exclusions:
the 12 months prior to the index admission (including first day of the index
admission)
• Discharged AMA
• Anterior myocardial infarction (index admission only)
• Other (non-anterior) location of myocardial infarction (index admission only)
Risk Variables: • History of CABG surgery
• History of PTCA
• 25 condition categories 32
 Acute Myocardial Infarction Metrics
ICD-10 code Description CC/MCC HCC CMS 30d
Mortality
R79.89 Other specified abnormal findings of blood -- -- NO
chemistry (troponin elevation)
I21.4 NSTEMI (Type 1 MI) MCC 86 YES
I21.3 STEMI of unspecified site MCC 86 YES
I21.9 AMI, unspecified MCC 86 YES
I21.A1 MI type 2 (due to demand ischemia) MCC 86 NO
I21.A9 Other MI type (3,4,5) MCC 86 NO
I24.8 Demand ischemia CC 87 NO
I24.9 Acute ischemic heart disease (ACS) CC 87 NO
I20.0 Angina, unstable CC 87 NO
I51.81 Takotsubo Syndrome CC -- NO
No code Non-traumatic Acute Myocardial Injury -- -- -- 33
 Pneumonia
• Pneumonia

34
 First Question:
What’s the Correct Status?

35
Medical Necessity – Should the patient be INPATIENT?
▪ Inpatient admissions will generally be payable under Part A if the
admitting practitioner expected the patient to require a hospital stay
that crossed two midnights and the medical record supports that
reasonable expectation

▪ All treatment decisions for beneficiaries were based on the medical

judgment of physicians

▪ CMS sought to respect the judgment of physicians

36
 Medical Necessity

▪ The care must be reasonable and necessary

▪ Must be clearly and completely documented in the medical record

37
 Pneumonia
Should this patient be inpatient?
▪ Clinical indicators such as SOB, Fever, Cough
▪ Infiltrate on CXR
▪ Abnormalities on Physical Examination
o Did anyone do a physical examination? Did anyone document it?

• Crackles
• Egophony
• Tactile fremitus
• Bronchial breath sounds
▪ Failed outpatient antibiotics
o Which antibiotics?

38
 Pneumonia
CURB 65

▪ Confusion

▪ Uremia (BUN >19)

▪ Respiratory Rate > 30

▪ Blood Pressure SBP < 90 or DBP < 50

▪ Age > 65

39
 Pneumonia Severity Index
Demographic: Age/Sex/Nursing ▪ AMS
▪ Respiratory Rate > 30
Home Resident ▪ SBP < 90
▪ Temp < 95𝑜 or > 103.8𝑜
Neoplastic disease/Liver ▪ Pulse > 125
disease/Heart Failure/CVA ▪ pH < 7.35
▪ BUN > 30
hx/Renal disease ▪ Sodium < 130
▪ Glucose > 250
▪ Hematocrit < 30
▪ PaO2 < 60
▪ Pleural Effusion
40
Do you have the right diagnosis?

41
 Pneumonia as Principal Diagnosis
▪ Will bucket into DRG 195 Simple Pneumonia or DRG 177
Respiratory Diseases
Clinical to Coding
Simple Pneumonia Complex Pneumonia
Simple Pneumonia and Pleurisy Respiratory Infections and Inflammations
MS DRG 195 194 193 179 178 177
Comorbid No CC/MCC w CC w MCC No CC/MCC w CC w MCC
RW 0.6868 0.9002 1.3167 0.9215 1.2744 1.8408
GLOS 2.6 3.3 4.2 3.2 4.3 5.5
Influenza PNA Viral PNA like adenoviral, Influenza PNA w/specified secondary PNA
unspecified Strep, H. flu; Mycoplasma, Tuberculous Fungal Virulent organisms like
Chlamydial BronchoPNA; Lobar PNA J18.9 CMV; RSV; K. pneumo; Staph; E. coli;
Pneumonia, unspecified HCAP! Legionnaires’;Gram negative Aspiration
Pulmonary Abscess
42
 Uncertain Diagnoses
▪ If the diagnosis documented at the time of discharge is qualified as

“probable”, “suspected”, “likely”, “questionable”, “possible”, or “still

to be ruled out”, or other similar terms indicating uncertainty, code

the condition as if it existed or was established.

43
 Pneumonia
▪ Probable gram-negative pneumonia, Rx Zosyn
▪ Probable MRSA pneumonia, Rx Vancomycin

▪ Suspected Aspiration pneumonia

▪ Clindamycin or Flagyl Rx

▪ All below Map to the DRG for Simple Pneumonia

▪ Community Acquired Pneumonia
▪ Healthcare Associated Pneumonia (HCAP)
▪ Nosocomial Pneumonia

44
 Pneumonia for ICD-10
ICD-10 code Description CC or MCC
J15.9 Unspecified bacterial pneumonia MCC
J18.9 Pneumonia, unspecified organism MCC
(includes CAP & HCAP & Nosocomial)

J69.0 Aspiration Pneumonia MCC

J15.6 Pneumonia due to gram negative bacteria MCC
J15.212 Pneumonia due to MRSA MCC
J15.8 Pneumonia due to specified bacteria (anaerobic) MCC
▪ Simple pneumonia maps to DRG 195 Pneumonia
▪ Specified codes map to DRG 177 Resp Diseases
45
Do you have the right diagnosis?

46
How many criteria for
Sepsis are there?

47
How many criteria for
Sepsis are there?

ONE
48
 Sepsis: If “Some” are due to infection
▪ SIRS criteria ▪ Hypoxemia (PaO2/FiO2 < 300)
▪ Altered Mental Status ▪ Acute oliguria (urine output <
0.5mL/kg/hr for 2 hours)
▪ Significant edema or positive fluid
balance ▪ Creatinine increase >0.5mg/dL
▪ Hyperglycemia in the absence of ▪ INR >1.5
diabetes
▪ Ileus
▪ CRP more than two SD above the
normal value ▪ Thromobocytopenia (PLT < 100,000)
▪ Procalcitonin more than 2 SD above ▪ Hyperbilirubinemia (> 4 mg/dL)
the normal value ▪ Hyperlactatemia (> 1 mmol/L
▪ Hypotension (SBP < 90 mmHg or SBP ▪ Decreased capillary refill or mottling
decrease > 40 mmHg)
49
Other criteria are for
Severe Sepsis

50
 Severe Sepsis

51
https://jamanetwork.com/journals/jama/fullarticle/2492881
 4 Cooperating Parties
▪ CDC – responsible for diagnoses (the government)
▪ CMS – responsible for inpatient procedures (the government)
▪ American Hospital Association – responsible for interpreting ICD-10
o Through Coding Clinic
▪ American Health Information Management Association (AHIMA) –
o Provides input from the coding community

Do you see the Society of Critical Care Medicine on that list?

52
 Severe Sepsis-3
▪ New Terms and Definitions

▪ (Severe) Sepsis is defined as life-threatening organ dysfunction (not

failure) caused by a dysregulated host response to infection.

▪ Organ dysfunction can be identified as an acute change in total SOFA

score ≥2 points consequent to the infection.

o A SOFA score ≥2 reflects an overall mortality risk of approximately

10% in a general hospital population with suspected infection.

http://jama.jamanetwork.com/article.aspx?articleid=2492875

53
 Severe Sepsis Organ Failure Assessment
Score – Acute change of 2 points due to the infectious process supports sepsis
System 0 1 2 3 4
Neurologic
15 13-14 10-12 6-9 <6
GCS
Respiratory < 200 with respiratory < 100 with respiratory
PaO2 /FiO2 > 400 < 400 < 300 support support
RA PaO2, O2 sat 84, 95% 84, 95% 63, 91% 42, 80% 21, < 80%
Cardiovascular Dopamine 5.1-15 or Dopamine > 15 or
Exam

Dopamine < 5 or
MAP > 70 mmHg MAP < 70 mmHg Dobutamine (any)
Epinephrine < 0.1 or epinephrine > 0.1 or
Norepi < 0.1 norepi > 0.1

Hepatic
< 1.2 1.2-1.9 2.0-5.9 6.0-11.9 > 12.0
Bilirubin, mg/dL
Coagulation
> 150 < 150 < 100 < 50 < 20
Platelets, x 1,000
Renal
< 1.2 1.2-1.9 2.0-3.4 3.5-4.9 > 5.0
Creatinine, mg/dL
Labs

UOP, ml/d < 500 < 200

Abbreviations: Catecholamine doses are in mcg/kg/min for at

PaO2: partial pressure of oxygen; FiO2: fraction if inspired oxygen; least 1 hour. 54
MAP: Mean arterial pressure
 Physician Advisors
▪ Time to change HATS!

55
 Back to Pneumonia
Do you have the right diagnosis?

56
 Pneumonia Cohort
Measure: 30-Day Risk-Standardized Mortality Rate Following Pneumonia
• Principal discharge dx of pneumonia or
• Principal discharge dx of sepsis (Excluding severe sepsis)
• with a secondary dx of pneumonia POA (and NO secondary diagnosis of severe
Dx Inclusions: sepsis POA)
• Not transferred from another acute care facility
• Age 65 or over
• Enrolled in Medicare FFS 12 months prior to index admission or VA beneficiary

• Discharged alive same day/next day, not transferred to another acute care facility
• Enrolled in Medicare hospice program or used VA hospice services any time in the 12
Exclusions:
months prior to the index admission (including first day of the index admission)
• Discharged AMA

• History of CABG surgery

Risk Variables: • History of PTCA
• 30 condition categories
If the patient is actually sick enough
to meet medical necessity, then you
meet “probably” Sepsis

58
 Timing of the Diagnosis
▪ H&P: “Probable Sepsis”
o Diagnosis made POA
• ER
• Hospitalist, especially Nocturnist
• Resident
o Will likely be the Principal Dx and drive the DRG
o Will risk adjust to Sepsis
o Will risk adjust to Severe Sepsis
• IF YOU WANT TO AVOID A DENIAL
59
 Severe Sepsis – SEP 1 Core Measure
The timing of the diagnosis is critical
SEP-1
o Severe Sepsis documented or ABSTRACTED
o Severe Sepsis ABSTRACTED – all three within six hours of one
another
a) Documentation of any (bacterial) infection
b) 2 or more SIRS Criteria
c) Organ Dysfunction

60
 Severe Sepsis
Sepsis-3 Publication Severe Sepsis 2012

Sepsis = Severe Sepsis Sepsis induced hypotension

All SOFA = Severe Sepsis Lactic Acid > 2
Urine Output < 0.5 mg/kg/hr for 2 hours
w/ fluids
ALI w PaO2/FiO2 < 250 w/o PNA
ALI w PaO2/FiO2 < 200 w PNA
Creatinine > 2
Bilirubin > 2
Platelets < 100k
Coagulopathy INR > 1.5
 Sepsis Clinical to Coding
Clinical to Coding
Sepsis-3 Publication Sepsis ICD 10 Coding

Sepsis = Severe Sepsis Sepsis

Severe Sepsis
Septic Shock

62
 Summary: Sepsis Clinical to Quality
Mortality Measures

Sepsis POA and Pneumonia POA bucket into Pneumonia Mortality

Severe Sepsis POA and Pneumonia POA bucket into Severe Sepsis

Mortality

63
Physician Advisor Knowledge

64
 Physician Advisor Skill Set
• Patient Safety Indicators • Physician Advisor Program
• Hospital Acquired Conditions • Status Assignment
•Mortality Risk Adjustment • Medical Necessity
Optimization
Quality UM • Extended Stay Reviews

Denials CDI • Documentation Education

• Peer to Peer Support • Case Reviews
• Appeals Support • Query Support
• Contract Review • HCC Education

65
 Thank you. Questions?

[email protected]

66