ACDIS | - How Via Web · Cerebral Palsy Example • 8 yo female, ex 34 weeker with history of...

©2015 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without express written permission.

2

Pediatric CDI: Lessons Learned From a Tertiary, Freestanding Children's Hospital

Jodi P. Carter, MD, CDI Physician Champion

Nancy C. Rush, RN, BSN, CCM, CDI Manager

Mary Ellen Fee, RN, CCDS, CDI Specialist

Phoenix Children’s Hospital

Phoenix, Arizona

3

Learning Objectives

• At the completion of this educational activity, the learner will be able to:

– Identify opportunities commonly found in pediatric tertiary medical centers

– Describe documentation opportunities found in the inpatient pediatric surgical population

– List two documentation opportunities found in pediatric ICU settings


4

Pollev.com/pchmeded

From any browser

PCHMEDED <your response>

From a text message

Participating With Poll EverywhereHow to Vote Via the Web or Text Messaging

22333

5

Participating With Poll EverywhereHow to Vote Via the Web

pchmeded

Example instruction slide without custom or simple keywords

6

Participating With Poll EverywhereHow to Vote Via Texting

Example instruction slide without custom or simple keywords

pchmeded


7

Practice Poll

8


9


• 385 licensed beds

• More than 70 subspecialty fields of pediatric medicine

• Over 18,000 inpatient admissions per year

• Over 16,000 surgical cases per year


10


• Provides approximately 60% of Arizona’s pediatric tertiary medical and surgical care for cardiac, orthopedic, neurologic, and oncologic populations

• Transplant services: Heart, renal, bone marrow, liver

• ECMO capability

• Level one trauma center

11


• Payer mix = approximately 60% Medicaid

• 2014–2015 U.S. News & World Report Best Children’s Hospitals

– Cancer

– Cardiology/heart surgery

– Neurosurgery/neurology

– Orthopedics

• Leapfrog Group Top Children’s Hospital

12

Phoenix Children’s Hospital CDI Program

• Established 2011

– Hospital CMI = local community hospital pediatric care

– Only one major DRG payer, but other contracts in active negotiation to convert to DRG

– 3 CDI specialists

– 1 physician champion

– Housed in finance with direct report to CFO


13

Get Your Cell Phones Ready!

14

Phoenix Children’s Hospital CDI Program

• Our perception of critical success factors:

– All team members share equal responsibility for project success

– Engage providers in a personal and professional manner

– Develop a user‐friendly program

– Create specific queries for individual diagnoses

– Choosing to retain all queries as a permanent part of the medical record

• Includes concurrent and retrospective queries

• Includes queries generated by either CDI or coding

15

Pediatric CDI Program Success

2011 2015

Hospitalwide CMI equivalent to local community hospitals’ pediatric care

CMI now in top quartile of freestanding children’s hospitals

Nonspecific documentation leading to lower reimbursement

Consistent financial contribution through improved documentation

Growing importance of public quality metric reporting

Improved public quality metrics (Leapfrog Group Top Children’s Hospital; U.S. News and World Report)

Only one major payer reimbursing by DRG, but actively renegotiating active commercial contracts

90% of payers reimbursing by DRG, including Arizona Medicaid (APR‐DRG)


16

DRG Systems

• MS‐DRG– Used by Medicare

– Identify the sicker patient with:

• CC = Complications and comorbidities– Example: Salmonella gastroenteritis

• MCC = Major complications and comorbidities– Example: Salmonella septicemia

– CCs AND MCCs ARE IDENTIFIED BY PROVIDER DOCUMENTATION

• APR‐DRG– Used by Arizona Medicaid

– Identify the sicker patient with:

• SOI = Severity of illness (1–4)

• ROM = Risk of mortality (1–4)

– SOI AND ROM INCREASE WHEN PROVIDERS DOCUMENT THE INTERACTION BETWEEN MULTIPLE DISEASE PROCESSES AND COMORBIDITIES

17

Pediatric CDI Program Success

CDI metric 2014

Physician response rate 99% average/year

Physician concurrence rate 75% average/year

DRG reassignment rate 34% average/year

18

Pediatric Hospitals ≠ Adult Hospitals


19


20

Top Performing Pediatric Opportunities

21

Pediatric Hospital Medicine

Children with complex chronic illness

• Multiple comorbidities

• Potential for long LOS

• Example: Cystic fibrosis

Healthy children with acute illness

• Few comorbidities

• High intensity/short stay

• High volume of respiratory disease

• Top 2 admissions by volume each year:

– Asthma

– Bronchiolitis


22

Maximizing Common Respiratory Illnesses

Common respiratory illnesses

• Asthma– Acute respiratory failure (MCC)

– Acute on chronic respiratory failure (MCC)

– All comorbid secondary conditions

• Bronchiolitis– Acute respiratory failure (MCC)

– Acute on chronic respiratory failure (MCC)

– All comorbid secondary conditions

• Capture isolation precautions (increases SOI)

Our definitions of respiratory failure

• Acute respiratory failure– Blood gas with pCO2 > 50,

pH < 7.35, pO2 < 60

– Initiation of positive pressure ventilation to maintain gas exchange

• Acute on chronic respiratory failure – Patient chronically on positive

pressure ventilation

– Blood gas with pCO2 > 50, pH < 7.35

– Increase in positive pressure ventilation

23

Cystic Fibrosis: A Challenge in Sequencing

• For a patient admitted with a CF exacerbation, should the exacerbation of CF always be sequenced first?

• Not always …– Ask yourself, “Is the reason for admission the cystic fibrosis itself

(e.g., poor compliance with home respiratory therapies has led to difficulty breathing) or a cystic fibrosis complication (e.g., an infectious bronchitis has led to difficulty breathing)?”

– If the reason is the cystic fibrosis itself, the principal diagnosis will be “cystic fibrosis with pulmonary manifestations” (277.02)

– If the reason is an infectious bronchitis, the principal diagnosis will be “infectious bronchitis” (466.0) and the CF will be a secondary diagnosis

• Reminder: Capture isolation precautions (increases SOI)

24



25

Pediatric Surgical Opportunities

26

Pediatric Surgical Opportunities

• Neurosurgery

– Brain compression

– Cerebral edema

• Orthopedic surgery

– Cerebral palsy

• General surgery

– Anemia from acute blood loss around the time of surgery

27

Neurosurgery

• Brain compression

INSTEAD OF DOCUMENTING PLEASE CONSIDER

Mass effectMidline shift

Brain compression (MCC)

Note: Incidental findings on an imaging study with no clinical impact should not be coded. There must be clinical impact.


28

Brain Compression Example

• 15‐mo‐old female with history of brainstem PNET. Despite chemotherapy tumor has grown. Admitted to hospital for surgical debulking.

• Pre‐op brain MRI: “There has been marked interval increase in size of irregular exophytic brainstem mass … with mass effect upon the optic nerves …”

• Progress note: “… s/p suboccipital craniotomy for resection of posterior fossa PNET …”

Mass effect with compression of the brain

Mass effect on imaging without clinical significance

Other Unable to determine

ORIGINAL REVISED

Weight 2.977 4.6927

SOI/ROM 1/1 3/4

Reimbursement Over $25,000

29

Neurosurgery

• Cerebral edema


Brain swelling Cerebral edema (MCC)Brain edema (MCC)

30

Cerebral Edema Example

• 6‐month‐old male presented to ER with fever, lethargy, and emesis. LP done in ER was concerning for gram‐negative bacterial meningitis. Patient admitted to PICU.

• Brain MRI demonstrated intra‐ventricular debris (that was concerning for pus) as well as some small loculated collections in the subdural space, and patient was started on Decadron.

• CSF culture ultimately grew H. flu.

H. flu meningitis with ventriculomegaly and cerebral edema

H. flu meningitis with ventriculomegaly and compression of the brain

H. flu meningitis with ventriculomegaly without compression or edema

Other

Unable to determine

ORIGINAL REVISED

Weight 2.2787 3.4974

SOI/ROM 3/2 4/3



31

Orthopedic Surgery


CP Specific type of cerebral palsy (plegia = paralyzed; paresis = weakened)

Cerebral palsy Topography: Monoplegia/monoparesis

Diplegia/diparesis (CC)

Hemiplegia/hemiparesis (CC)

Paraplegia/paraparesis (CC)

Triplegia/triparesis (CC)

Tetraplegia/tetraparesis (MCC)

Quadriplegia/quadriparesis (MCC)

Spasticity: Spastic

Non‐spastic

Note: When a CP patient has quadriplegia, you should not look for an additional code of “functional quadriplegia.” It is inherent to the code of CP quadriplegia.

32

Cerebral Palsy Example

• 8 yo female, ex 34 weeker with history of cerebral palsy and GERD admitted for Nissen fundoplication

Congenital quadriplegic cerebral palsy

Congenital diplegic cerebral palsy

Congenital paraplegic cerebral palsy Other

Unable to determine

ORIGINAL REVISED

Weight 1.38 5.68

SOI/ROM 2/1 2/2


33

Surgery

• Acute blood loss anemia


Low hemoglobin Anemia due to acute blood loss from a disease (name the disease) (CC)

Low hematocrit Anemia caused by acute blood loss from surgical complication (name the complication) (CC)

Decreased RBC count Low hematocrit from hemodilution (not a CC)


34

Acute Blood Loss Anemia Example

• 16 yo female with a history of idiopathic scoliosis that is now > 50 degrees

• Admitted for posterior spinal fusion, T3 ‐> L3

• EBL = 1000 cc; 525 cc cell saver given

• H/H 10.0/30.2 7.2/20.4

• Postoperatively patient becomes tachycardic, PRBCs given

• Note: You must account for the expected dilutional effect on H/H when making the decision to query for this diagnosis postoperatively

Acute blood loss anemia Chronic blood loss anemia

Acute on chronic blood loss anemia Other

Unable to determine

ORIGINAL REVISED

Weight 5.0565 6.3425

SOI/ROM 1/1 2/1


35

Pediatric ICU Opportunities

36


• PICU

• NICU

• CVICU


37


• Respiratory failure


Tracheostomy dependentVentilator dependentBiPAP dependentCPAP dependent

Chronic respiratory failure (CC)

Increased work of breathing Acute respiratory failure (MCC)

Acute on chronic respiratory failure (MCC)

Note: Clinical correlation needed to confirm appropriateness of these CCs and MCCs

38

Example: Respiratory Failure

• 6 mo female with hx of type I SMA (on BiPAP at all times) admitted to PICU with increased thoracic/abdominal asynchrony and increased work of breathing

• ABG shows pCO2 = 60

• In PICU BiPAP settings increased above baseline and aggressive airway clearance initiated

• Provider queried for respiratory failure:

Acute respiratory failure Acute on chronic respiratory failure

Chronic respiratory failure Other

Unable to determine

ORIGINAL REVISED

Weight 0.9091 2.0549

SOI/ROM 3/2 3/3


39


• Shock


Hypotension Shock (CC)

SPECIFIED shock (MCC)


40

Example: Shock

• 13 yo female with hx of a “genetic syndrome,” global developmental delay, spastic quadriplegic CP, epilepsy, GERD, and neuromuscular scoliosis admitted for posterior spinal fusion.

• L pleural space entered while dissecting to the spine. Pt became hypotensive. Dopamine drip started. Crystalloid, albumin, PRBCs, FFP, and cell saver given in OR. Transferred to PICU on dopamine drip, intubated, and hypothermic with a SBP in the 50s.

ORIGINAL REVISED

Weight 1.8091 3.0782

SOI/ROM 3/2 3/2


Hypotension without shock Postoperative cardiogenic shock during/resulting from surgery

Postoperative hypovolemic shock Postoperative shock during/resulting from surgery

Other Unable to determine

Note: This example assumes the CDI specialist is aware of the connection between the pneumothorax and the shock state. In this example, there is also a coding opportunity for iatrogenic pneumothorax.

41

Neonatal ICU Opportunities

• Neonatologists forget how sick their patients are

– Acute respiratory failure (MCC)

– Cardiogenic shock (MCC)

42

Cardiovascular ICU Opportunities

• Hypoplastic left heart syndrome (MCC)

• Three phase surgical correction

– Norwood

• Performed within the first 2 weeks of life

– Bi‐directional Glenn shunt

• Performed between the ages of 4 and 6 months

– Fontan

• Performed between 18 months of age and 3 years of age


43

Hypoplastic Left Heart Syndrome


“s/p Norwood” Hypoplastic left heart syndrome (MCC)

“s/p Glenn”

“s/p Fontan”

44

Thank you. Questions?

[email protected]@[email protected]

In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section at the front of the program guide.

ACDIS | - How Via Web · Cerebral Palsy Example • 8 yo female, ex 34 weeker with history of...

Documents

Transcript of ACDIS | - How Via Web · Cerebral Palsy Example • 8 yo female, ex 34 weeker with history of...