#3400.1

59 R

ev. 1

0/1

6

Department of Quality

Documentation

Has anyone ever heard of

QD? CDI? Queries?

Quality Documentation’s

RoleWe review charts to find missing, conflicting documentation, and/or to specifydiagnoses to make sure there is a clear, accurate and complete picture of the patient’s hospital stay.

• Concurrently review the in-patient chart, usually by day 3-4 of hospital admission. We also do retrospective reviews for coders and for second level reviews (PSIs, HACs, Mortality).

• Seek to clarify any documentation that is unspecified, unclear, conflicting or missing.

• Send queries to providers to obtain any additional clarifying documentation.

• 95% of queries sent are quality impacting, only 5% financial.

• QD & Coding is a resource team that works in collaboration.

• Queries can be sent after discharge.

2

Your documentation tells the patient’s

story.

H&P = Introduction

Progress/Op Notes = Body

Discharge summary = Conclusion

It is critical to paint a clear picture from start to finish

and cover the initial situation, changes through the

stay, and a clear summary that brings it all together.

How does your documentation

make a difference?

First and foremost, accurate documentation helps provide cohesive and collaborative care for the patient.

• Support medical necessity

• Helps support need for outpatient rehab and programs

• Accurately capture Severity of Illness and Risk of Mortality scores

• Length of stay

• Support CMI (case mix index) compensation

• Decrease denials

• Accurately reflect quality indicators and publicly published outcome measures

• Accurately reflects the conditions treated, monitored and resources utilized throughout that patients stay

• Represents the care you provided to your patient

• Provider quality scores

4

Documentation Tips

• Document the diagnosis(es) rather than signs and symptoms.

Example: SOB due to Acute Respiratory Failure

• Be specific with type and acuity! Acute, chronic, acute on

chronic, or exacerbation.

Example: Acute on Chronic Systolic Congestive Heart

Failure; Acute Blood Loss Anemia; Chronic

Pancreatitis

• Link diseases /diagnoses to their underlying causes.

Example: Pancytopenia due to chemo; Anemia due to CKD

• Caution when using the term “postop” or “postoperative”. CMS

takes this as a postoperative complication and not a timeframe.

Documentation Tips continued…

• Use your consults! • Dietician notes- Malnutrition with severity

• Wound care- Pressure Injuries (be SPECIFIC)

• Clarify diagnoses that are present on admission (POA)

Example: Pressure Injuries, DVT, Fracture

• Avoid use of arrows/symbols and abbreviations (e.g. ↓low sodium, low plt, abnormal hgb, PNA, ARF)

Example: Hypernatremia, Thrombocytopenia, Iron Deficiency Anemia; Pneumonia; Acute Respiratory Failure

• Clarify the significance of laboratory, radiology and other procedures by summarizing these results in your documentation. Diagnoses can not be coded from these reports per CMS rules and guidelines.

*Do not copy and paste*

Terms of UncertaintyAll of the following documentation terms are considered “terms

of uncertainty” by CMS. This means diagnoses documented

with these terms do not generate an ICD-10 code and a query

will be sent for clarification or to rule in/out the diagnosis.

• Covering for, in the setting of Not acceptable as

confirmed or suspected per CMS guidelines

• Consistent with, compatible with, indicative of, concern

for, suggestive of, comparable with, probable,

suspected, likely, questionable, possible If this

documentation is followed through to DC Summary, a

query will not be sent.

Terms of Certainty

• Associated with

• Evidence of

• Treating as

• Treated as

These terms will all generate an ICD-10 code and a

query would not need to be sent.

Severity of Illness (SOI)

&

Risk of Mortality (ROM)

These are quality measures that affect population health. Risk of mortality and severity of illness are becoming a vital part of the

health record.

Hospital Acquired Conditions (HAC)

and Patient Safety Indicators (PSI)

– Foreign object retained after surgery– Air embolism– Blood incompatibility– Pressure injuries– Falls– Manifestations of poor glycemic control– Catheter-associated urinary tract infection– Vascular catheter-associated infection– DVT/ pulmonary embolism after lower extremity an operation– Surgical site infection– Post operative DVT/PE, Respiratory Failure & Sepsis

– If you are not able to determine present on admission status for these conditions- “unable to determine” choice does not code to a HAC.

Pneumonia Specificity• Even if no sputum cultures obtained or cultures are negative, you can

still document “Treating/treated as” to help accurately capture the treatment given for the pneumonia.

Example: “…Patient pneumonia treated as gram negative…” or “…treating as aspiration pneumonia…”

• Negative or inconclusive sputum cultures do not preclude a diagnosis of a specific bacterial pneumonia in patients with the clinical evidence of this condition. Pneumonia can be specified based on the treatment (per American Hospital Association Coding Clinic).

• If you are treating a suspected, possible or probable gram negative or other resistant pneumonia please document as such (must be carried to DC Summary).

• CAP and HCAP are not considered specified by CMS, and only code to Simple Pneumonia.

12

Pneumonia

Observer A Observer B Observer C Observer D

Principal

Diagnosis

Simple

Pneumonia,

unspecified

Simple

Pneumonia,

unspecified

Simple

Pneumonia,

unspecified

Complex

Pneumonia:Treating Gram

Negative

Secondary

Diagnoses

w/o CC/MCC w/CC AKI w/MCC ARF w/MCC ARF

Medicare DRG 195 194 193 177

MS-DRG

AMLOS

3.3 4.4 5.8 8.2

Relative

Weights

0.7111 .9695 1.4261 2.0549

Severity of

Illness

Risk of

Mortality

Level 1/minor

Level 1/minor

Level 2/mod

Level 1/minor

Level 3/major

Level 3/major

Level 3/major

Level 3/major

Reimbursement $5,024.61 $6,541.63 $9,222.24 $12,023.79

COPDObserver A Observer B Observer C

Principal

DiagnosisCOPD

Exacerbation

COPD

Exacerbation

COPD

Exacerbation

Secondary

Diagnosesw/o CC/MCC w/CC Chronic

Diastolic/Systolic

CHF Oral Lasix -chronic

home medication

w/MCC Acute

Diastolic/Systolic

CHFIV Lasix

Medicare DRG 192 191 190

MS-DRG AMLOS 3.3 4.0 4.9

Relative Weights 0.7313 0.9321 1.1578

Severity of Illness

Risk of MortalityLevel 1/minor

Level 1/minor

Level 2/moderate

Level 2/moderate

Level 2/moderate

Level 2/moderate

Reimbursement $5,143.20 $6,322.03 $7,647.09

Common Queries Sent to ProvidersGen Med: Obesity/Morbid Obesity, Malnutrition, Pressure Injuries, CHF,

Sepsis, Respiratory Failure, Encephalopathy, CAUTI, Conflicting

Documentation “Captain of the Ship”

Pulmonary/ICU: Acute and/or Chronic Respiratory Failure, Pneumonia

Specificity, Shock, Sepsis

Cardiology: Afib/Aflutter Specificity, CHF, STEMI/NSTEMI/MI2/Demand

Ischemia

Neurology: Encephalopathy, Cerebral Edema, Brain Compression

ID: Pneumonia Specificity, HIV/AIDS

Surgery: Postop Complications, Acute Blood Loss Anemia,

Thrombocytopenia, Obesity/Morbid Obesity, Malnutrition, OP Note

Clarification

Top QueriesAcross the system (excluding Golisano’s), the top queries for all providers consistently are as follows:

• Obesity/Morbid Obesity ALWAYS clinically significant as it can impact nursing care, equipment, etc. BPA fires for BMI over 25.

• Malnutrition Look for your dietary consult notes, BPA will fire if noted by dietary. Must be specified. Patient can have malnutrition with BMI over 19.

• Pressure Injuries Often noted in nursing documentation flowsheets, but never mentioned in MD notes.

• Congestive Heart Failure Must be specified by type and acuity.

The Query Process• A query is an electronic question posed to a provider by a

QD Registered Nurse.

• Most queries are derived from a template bank and are

usually in a multiple choice format.

• All queries are meant to be non-leading and the best

judgment of the practitioner is advised.

• Once answered and signed, the query becomes a

permanent part of the medical record.

17

Answering The Query

• If a query is sent, it will populate in your EPIC in-basket for

chart completion.

• A query that is sent on a template can be answered in just

a few clicks.

• Select a response from the drop down menu of options or

manually fill in the appropriate response as needed.

• A signed query becomes a progress note.

• Physicians can grant access to their EPIC in-basket to their

advanced practitioners to answer the queries. This can be

arranged through EPIC support staff.

18

Notice the phone number! Always call if you have ANY questions!!!

What if I don’t answer?

• QD personnel are required to notify providers of existing queries 48 hours after being sent. This can be done through email, AMION/Voalte text, paging system, office messages or personally if seen on campus.

• After 72 hours, the query is then placed on a deficiency list for VPs and Physician Advisors to review.

• QD personnel are located on each campus M-F to provide assistance or answer questions. Every query has a QDS phone number you can call for any questions!

Are you going to be

documenting in EPIC daily?

• Tired of searching through HUNDREDS of diagnoses?

• Want to make sure your diagnosis generates an ICD-10 code and is CMS

APPROVED?

• Contact Quality Documentation to set up your EPIC preference list!

Health Park: Robin Krainer (239) 343-8118

Cape Coral: Jenna Prisciandaro (239) 343-8135

Lee: Jenna Prisciandaro (239) 343-8135

Gulf Coast: AnnMarie Perlmutter (239) 343-8173

Creating your preference list takes less than 10 minutes and allows you to chart faster with better accuracy.

Creating a Preference List in EPIC

Visit us on Intralee!

Physician Documentation Resources

Includes past education on a variety of topics.

#3400.1

59 R

ev. 1

0/1

6

The following physicians serve as liaisons for the Quality Documentation Department:

William Carracino MD, Vice President & Chief Medical Information Officer

Michael Bolooki MD, Medical Director of Informatics

If you would like to reach out to Dr. Bolooki for a peer to peer discussion, please email him at michael.bolooki@leehealth.org

Thank you

Any Questions?

Last Updated 2/12/2020 JP

27