Mortality Reviews

edited March 2016 in Clinical & Coding
Does anyone have a good template/guideline/form to use for mortality reviews? If someone has one they would like to share, I would be grateful! Thanks so much!-Vicki

Vicki S. Davis, RN CDS
Clinical Documentation Improvement Manager
Health Information Management Department
Alamance Regional Medical Center
Office (336) 586-3765
Ascom Mobile (336) 586-4191
Fax (336) 538-7428
vdavis2@armc.com

"The difference between the right word and the almost right word is the difference between lightning and the lightning bug."- Samuel "Mark Twain" Clemens


______________________________________________________________________
Notice: The information contained in this message (Including attachments) is covered by the Electronic Communications Privacy Act, 18 U.S.C. 2510-2521, is confidential and may be legally protected from disclosure. If you are not the intended recipient, or an employee or agent responsible for delivering this message to the intended recipient, you are hereby notified that any retention, dissemination, distribution or copying of this communication is strictly prohibited. If you have received this communication in error, please notify the Sender immediately by replying to the message and deleting it from your computer. ______________________________________________________________________

Comments

  • edited March 2016
    I don't have a template but I'd love to see one. I review every mortality record after it has been draft coded but prior to it being dropped by CBO. Things I monitor and check are correct/maximized DRG, SOI/ROM, complication codes, significant secondary dx, etc. I also have been asked to track if they were DNR on arrival, when were they made DRN, days in comfort care, if we had a d/c summery for coding (yes, we don't always have one), etc. I have worklist in Midas and have built in all the necessary fields so that I can pull reports regarding my personal impact as well as any demographics related to the patients.

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404
  • edited March 2016
    I'd very much like to see a template too.



    Robert



    Robert S. Hodges, BSN, MSN, RN, CCDS

    Clinical Documentation Improvement Specialist

    Aleda E. Lutz VAMC

    Mail Code 136

    1500 Weiss Street

    Saginaw MI 48602



    P: 989-497-2500 x13101

    F: 989-321-4912

    E: Robert.Hodges2@va.gov



    "Patriotism is easy to understand in America; it means looking out for
    yourself by looking out for your country" Calvin Coolidge



  • edited March 2016
    Right now, I am reviewing retrospectively as well. I look at the Age, Uni=
    t, DRG, SOI/ROM scores, Pdx, mcc/cc's, secondary dx's, DNR/Palliative stat=
    us (and if we are still coding it in the top 9 for the quality measures), =
    and whether the case was reviewed by a CDS or not.

    All of this work to find out what we already know-the SOI/ROM scores are u=
    sually 4/4 when CDS was involved. Is anyone shocked??????????? Lol.

    We are getting ready to start reviewing all charts before coding drops the=
    bill when the SOI/ROM scores are less than 4/4. I started a spreadsheet =
    to help me track the info, but it seems awkward and cumbersome. I attache=
    d a sample of the spreadsheet without any specific patient identifiers. A=
    nyone have any suggestions for improvement?

    Thanks so much-V



    Vicki S. Davis, RN CDS
    Clinical Documentation Improvement Manager
    Health Information Management Department
    Alamance Regional Medical Center
    Office (336) 586-3765
    Ascom Mobile (336) 586-4191
    Fax (336) 538-7428
    vdavis2@armc.com

    "The difference between the right word and the almost right word is the di=
    fference between lightning and the lightning bug."- Samuel "Mark Twain" Cl=
    emens

  • edited March 2016
    Vicki,

    One thought I had looking at it quickly, it might be worthwhile to add 2 columns where you would put in the # of cc's and the # of mcc's (in addition to listing them out as you've done).

    Additionally, are you posing retrospective queries to capture additional diagnosis? or suggestions to coding to add additional diagnosis that you feel are documented but not coded? Fields to capture those activities (and the outcomes, MD answered, coder agreed, what & number of additional diagnosis...)

    If you (or anyone else) are members to UHC, they have full detail available about their mortality models so you can know exactly what does / does not impact mortality for any particular DRG.

    Don

  • edited March 2016
    That's basically what I started out with when I began this over a year ago. I had an Excel sheet too. Are you going to be impacting these records in any way? We had columns for if retrospective queries were placed, response, dx added, DRG changes, etc as well as just a general notes column.
    The problem we ended up having is that every time I reported back to our director and MD liaison, they wanted additional data. Generally it was demographic data that was already in our electronic system (Midas) but I had not included it in my report. Also, when you begin doing these reviews, things just start coming up. I hope other hospitals don't have this issue but I don't think administration was aware that we have many death charts without d/c summaries (!!!). So then of course they wanted to know how many and which Dr's etc. It just kept growing.... This is why I ended up working with IT to create a formal registry. This way when they want to then look at any additional info (ethnicity, consults, ICD-9's, etc), I (meaning a data analyst does it for me) can pull out whatever they request. I can also pull out a pre-built Face Sheet with the review data as well as pertinent demographics and all the ICD-9 codes and print that. This only became important because our death records are highly scrutinized by MD's. They are looking at their own quality data at this point via CRIMSON and the first thing they generally want to focus on is the death charts. This is why we decided it was super important to ensure that the coding was accurate and any opportunities to improve their SOI/ROM has been handled. I'm sure not every hospital is dealing with this same issue, but that's our context.

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404

  • edited March 2016
    Thanks you guys for the info! I can pull a report of all expired patients/codes/drg's/demographics, etc. (which of course I found that out after I started the spreadsheet...) I also receive an email with pertinent info about 2 hours after each pt expires. We are still tracking data for June and will start a trial run of pre-billing reviews July. We track CDS impact in a different database for all other reviews, so I will have to compare the data. Let's keep this topic alive and brainstorm to help each other. Maybe this would be a good "joint project" to get up and running since it is such a hot topic...-V

    Vicki S. Davis, RN CDS
    Clinical Documentation Improvement Manager
    Health Information Management Department
    Alamance Regional Medical Center
    Office (336) 586-3765
    Ascom Mobile (336) 586-4191
    Fax (336) 538-7428
    vdavis2@armc.com

    "The difference between the right word and the almost right word is the difference between lightning and the lightning bug."- Samuel "Mark Twain" Clemens

  • edited March 2016
    Our mortality review process is more of a clinical review that includes
    physician review and documentation of opportunities to improve
    processes/outcomes. It is based on info collected by the CDS and coders,
    including DNR status, comfort care, SOI/ROM scores, secondary dx, etc
    but then prompts the reviewing physician to add comments as appropriate
    (see highlighted fields). Mortality review is a standing agenda item at
    our monthly core measure team meetings.


    Bonnie Zahn, RHIA, CHP, CHDA

    Director, Health Information Management

    Underwood-Memorial Hospital

    509 N. Broad Street

    Woodbury, New Jersey 08096



    Phone: (856) 853-2112

    Fax: (856) 251-0997

    E-Mail: zahnb@umhospital.org


  • I have reviewed all mortalities from inpt, OBS, rehab, outpt surg etc.
    What I noticed is the tendency to choose the main diagnosis and drop the bill.

    I am unfamiliar with how outpt/ED is billed but have noticed many 'rebills' when the information requesting additional diagnoses was relayed to coding.



    Charlene Thiry, RN, BSN, CPC, CCDS
    CDI Consultant
    Phone: 913-796-5944
    charlene.thiry@TrustHCS.com
    www.TrustHCS.com

    Read our blog: http://www.trusthcs.com/blog/


  • I review all mortalities regardless of payer and status OB/ER/inpatient/outpatient. Our facility O/E ratio is higher than last year so this has become a priority issue.
    Amy Fenton, R.N.
    Clinical Documentation Specialist
    Bronson Hospital
    Quality and Safety
    601 John Street
    Box 59
    Kalamazoo, MI 49007
    Phone 269-341-8442
    Fax 269-341-8330
  • It is my understanding that O:E only includes inpatients? I could be wrong on that (wouldn't be the first time) but as far as I know that's how it works. I began review all IP mortalities 4 years ago for the same reason, our O:E had been on a steady incline for years without a CDI program.
    As for the payment part, I also am not overly familiar with OP billing but it is my basic understanding that payment is based off of the CPT codes rather than the I-10 diagnostic codes. This is why OP CDI is so different than IP.

    If I am incorrect and metrics like O:E or financial reimbursement would be impacted by my reviews, I want to include OP encounters in this process. But it they won't be impacted, I will punt these reviews to quality for identification of any quality improvement opportunities and continue to only review IP.

    Thanks for your input!

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404
  • Our understanding is also that this metric only comes off inpatient data... additionally only those diagnosis that are POA Y impact the mortality expected rate. We worked extensively with coding to clear up some misconceptions on POA Y... Like hypokalemia documented on day 3 but was present on admission if you looked at lab work... and stuff like that. (remember a lot of the diagnosis that impact mortality (AHRQ's) are NOT cc/mcc's)

    Also remember that since mortality is a "30 day all cause" make sure you have their discharge status correct, since discharging to hospice will exclude them from coming back into your data if they die within 30 days of discharge.

    Liz
  • We do not include Hospice at our institution!

    Juli
    Juli Bovard RN CCDS
    Certified Clinical Documentation Specialist
    Clinical Effectiveness/Clinical Quality
    Rapid City Regional Hospital
    755-8426 (work)
    786-2677 (cell)
    "No Limit to Better......"
    [CCDS_pin_1inch]



  • edited March 2016
    Hi Kerry,

    If they were admitted as an acute inpatient then yes we would review the case. Admin has flip flopped a couple of times and has now removed out-patient from our population.

    Vanessa Falkoff RN
    Clinical Documentation Improvement Coordinator
    University Medical Center of Southern Nevada
    1800 W Charleston Blvd
    Las Vegas, NV
    vanessa.falkoff@umcsn.com
    office 702-383-7322

    Compassion * Accountability * Respect * Integrity

  • edited March 2016

    No, we exclude from the population of reviews.

    On Thu, Feb 18, 2016 at 3:58 PM, CDI Talk wrote:

    > We do not include Hospice at our institution!
  • edited March 2016
    Mortality reviews were just added to our workflow and if they were admitted as an acute inpatient we are asked to review them.

    Debbie Smith, RN, CCDS, CCS
    UT Southwestern Medical Center at Dallas-
    William P Clements and Zale Lipshy University Hospitals
    6201 Harry Hines Blvd.
    Dallas, TX 75390
    214-645-5217
    Deborahw.smith@utsouthwestern.edu


    Sent from my iPad

  • Kerry

    What I have been able to discern, in some quality models, if a patient qualifies for Inpatient Hospice Services, an order is written for same, and the service is reported as Hospice, these patients are not included in the Mortality Outcomes data and are not tabulated as an expired outcome for acute inpatient admission. Your site is required to have a license for a hospice designation.

    Paul

    Paul Evans, RHIA, CCS, CCS-P, CCDS

    Manager, Regional Clinical Documentation
    Sutter West Bay
    633 Folsom St., 7th Floor, Office 7-044
    San Francisco, CA 94107
    Cell: 415.412.9421



    evanspx@sutterhealth.org

    [cid:image001.jpg@01D16A54.BC524380]

  • edited March 2016
    Just reading through all of the responses-thanks for the feedback and great advice as always.
    I've been conducting mortality reviews on all inpatients (including hospice) since 2010.


    Kerry Seekircher, RN, BS, CCDS, CDIP



Sign In or Register to comment.