Mortality Review
We are just beginning to delve into mortality review here at my
facility. I started by stratifying inpatient mortality discharges into
APR ROM scores. It makes sense to start with the 1's and 2's to see if
there are any diagnoses that could be documented in a more "codable"
manner, but I have some questions and hope that those of you who have
been doing this for a while will share your expertise.
My main question is this: What do you do about the organ failures that
inevitably result in death but do not really meet the UHDDS criteria for
reportable secondary diagnoses? I participated in the ACDIS conference
call last week and heard Dr. Gold's opinion that any diagnoses that
occur after the patient is made comfort care should not be coded. This
does make sense, but I wonder how others are handling this issue.
More questions:
* Do you factor in the SOI score or just use ROM if you are
using APR-DRG methodology? (I have the 3M APR grouper available to use).
* How do you use your physician advisor for mortality review?
* What do you do with the results of your review?
* Do you have a different methodology for inpatient mortality
and 30 day post discharge mortality?
* Can you give me a good reference for the severity adjustment
methodology used to risk adjust 30 day post-discharge mortality?
Thanks in advance. I'm looking forward to the group's input.
Cathy Seluke, RN, BSN, ACM, CCDS
Supervisor Clinical Documentation Compliance
MaineGeneral Medical Center
Augusta and Waterville, Maine
(207) 872-1796
Cathy.Seluke@mainegeneral.org
facility. I started by stratifying inpatient mortality discharges into
APR ROM scores. It makes sense to start with the 1's and 2's to see if
there are any diagnoses that could be documented in a more "codable"
manner, but I have some questions and hope that those of you who have
been doing this for a while will share your expertise.
My main question is this: What do you do about the organ failures that
inevitably result in death but do not really meet the UHDDS criteria for
reportable secondary diagnoses? I participated in the ACDIS conference
call last week and heard Dr. Gold's opinion that any diagnoses that
occur after the patient is made comfort care should not be coded. This
does make sense, but I wonder how others are handling this issue.
More questions:
* Do you factor in the SOI score or just use ROM if you are
using APR-DRG methodology? (I have the 3M APR grouper available to use).
* How do you use your physician advisor for mortality review?
* What do you do with the results of your review?
* Do you have a different methodology for inpatient mortality
and 30 day post discharge mortality?
* Can you give me a good reference for the severity adjustment
methodology used to risk adjust 30 day post-discharge mortality?
Thanks in advance. I'm looking forward to the group's input.
Cathy Seluke, RN, BSN, ACM, CCDS
Supervisor Clinical Documentation Compliance
MaineGeneral Medical Center
Augusta and Waterville, Maine
(207) 872-1796
Cathy.Seluke@mainegeneral.org
Comments
It is interesting to hear the physician responses when they see their patient numbers. I have had mortality records with only one or two codes (SOI/ROM 1/1 or 1/2) which move to 3/4- 4/4 with two or three additional diagnoses.
The goal of course it to have all deaths a 4/4 - does not always occur.
I also listened to the conference call. I do not query for organ shut down unless there is very good documentation to support a query.
i.e. nursing documents: labored breathing, RR of 34, sats dipping into the 70's, bumped 02 up
On rare occasion there is a physician who documents the clinical indicators.
On a lot of the 'comfort care' patients there is little to no documentation to support an organ failure query.
Charlene
For your "main question": I have never considered that ANYTHING documented to have occurred after a move to Comfort Care as not being codeable, but I would agree that this is generally how it works. That being said, it depends. There are certainly situations where it may be appropriate to code. Especially when/if you have a patient on CC for an extended period of time. Or, you have a patient admitted that quickly moves to Comfort care. I did not hear Dr. Gold's opinion, but I have read this article several times to try to look for some guidance. It is several years old though...
http://www.hcpro.com/acdis/details.cfm?content_id=230011
Our review process involves me reviewing the record retrospectively with a draft coding summery provided by coding. I am focusing on accurate Pdx, DRG, Primary procedure and all significant co-morbidities. I use both SOI and ROM as indicators. That being said, even if we are at a 4/4, I will still provide feedback as to missing CC/MCC's in the coding summery. However, I only query the MD if there will be impact on the DRG or SOI/ROM. For example: if I see encephalopathy documented in the record, I will ask the coder to consider adding the code even if we are at a 4/4 in DRG 871. But, if encephalopathy was not documented but the clinical indicators are there in this scenario, I would not hold up the record to query, as there would be no impact.
I contact our PA if we have a low SOI/ROM on a death record that I do not see any way to impact. Any death record coded with either an SOI or ROM of 2 or lower, will be sent. I also send him cases that are 3/3 if they were unexpected deaths that I know will be of interest down the road. For ex: an elective shoulder that codes post-op.
We have created an electronic registry housed within MIDAS where I enter my reviews. I track whether I queried, any added CC/MCC's, Pdx change, DRG change, etc, as well as a few unrelated things that have been asked to watch for. Because this is also in our MIDAS system, I am able to then add all demographic data and that type of info if needed. I can then pull reports of all the data and what my impact has been. I have only actually done this once.
30 day mortalities are not treated any differently in our process.
I will admit our process is very time-intensive, it routinely involves multiple conversations with coders and sometimes an additional review by our coding manager. However, the impact has been significant and both the coders and myself have learned a ton through the process.
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
We should code a condition that meets the UHDDS Guidelines - The criteria to capture these conditions as mandated by ICD-9-CM official guidelines are the diagnosis must be clinically monitored, evaluated, or treated, and/or result in an extended length of stay (LOS), and require nurse monitoring.
Example: I reviewed a case whereby a patient was admitted with ICH with 'significant midline shift'. The record documented the 'midline shift' led to the decision to place the patient on Comfort Care because of the severity of the shift. A neurologist documented the severity of the shift gave the patient zero chance of a meaningful life. He stated it would be futile to treat the 'shift' with surgical measures and/or drugs. He recommended Comfort Care, and this was the course undertaken. The patient expired with a ROM of "2". I was asked to review the chart.
Key Point: The Radiology Report documented a clear, unambiguous and significant hernia of the Brain.
The term midline shift can't be coded - the ROM was 2 with the ICH as principal Dx.
The hernia of the brain was not treated, and lead to the decision to make the patient Comfort Care. The hernia of the brain justified and explained WHY the patient was made comfort care.
KEY CONCEPT: Clinical evaluation means the medical staff is aware of the condition and is evaluating it in terms of evaluation, testing, consultations, and clinical observation of the patient's condition and/or the existence of the condition affect the types or choices of treatment rendered to the patient.
The Attending agreed this was a hernia, the chart was compliantly amended, and the correct ROM of "4" was reported.
The ROM was 4 with the hernia of the brain.
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.637.9002
Fax: 415.600.1325
Ofc: 415.600.3739
evanspx@sutterhealth.org
Dawn
* Do you factor in the SOI score or just use ROM if you are using APR-DRG methodology? (I have the 3M APR grouper available to use). We review for ROM at this time, but Medi-Cal with soon use the APR-DRG methodology with SOI for reimbursement.
* How do you use your physician advisor for mortality review? Generally - no. The CDI team reviews and will query the attending if we see significant abnormalities charted w/o a clear diagnosis.
* What do you do with the results of your review? Share them the MD VP of Quality
* Do you have a different methodology for inpatient mortality and 30 day post discharge mortality? No 30 day review.
* Can you give me a good reference for the severity adjustment methodology used to risk adjust 30 day post-discharge mortality?
Anything expired case that is 2/2 or less, we review. However, all cases count, not 'just' the expired cases. However, given it is not possible to review all admits, we find it helpful to review the mortality cases with low scores. Generally, we can find a legitimate change leading to a better score in 50% of the cases reviewed. Again, we do this w/o any PA or MD input as they are not available. We use our existing library of query forms to review cases for clinical criteria.
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.637.9002
Fax: 415.600.1325
Ofc: 415.600.3739
evanspx@sutterhealth.org
Sharon Cole, RN, CCDS
Providence Health Center
Case Management Dept
254.751.4256
Sharon.cole@phn-waco.org
Katy Good
Katy Good
I hope we all agree that this statement is not valid: ' IF condition X is not treated, THEN it can't be coded". I hear this often, and it is not a valid statement.
One More Example:
Patient is on Home Hospice - declines rapidly and family takes said pt to ED despite prior decision for Hospice.
Family decides to Admit and the Medical Staff documents the patient is in Septic Shock due to PNA with Acute Respiratory Failure. MD convinces family best course of action is Comfort Care and family agrees. No Goal Directed Therapy or curative intervention directed towards the Sepsis, shock, PNA or Respiratory Failure - however, all qualify for reporting as 'evaluation' criteria for UHDDS is met, and conditions explain the clinical picture and rationalization for Comfort Care.
Paul E.
Paul Evans, RHIA, CCS, CCS-P, CCDS
Cindy
Sharon Cole, RN, CCDS
Providence Health Center
Case Management Dept
254.751.4256
Sharon.cole@phn-waco.org
Katy -- you've outlined a very nice process, one that I suspect is similar to many that seriously review mortality cases.
As Paul also said, though all cases affect mortality profiling and observed to expected ratios, there needs to be a pragmatic focus as to what is possible to actually achieve.
I review all mortality cases that have a LOS
Notice use of word "OR" in below statement.
For reporting purposes the definition for "other diagnoses" is interpreted as additional conditions that affect patient care in terms of requiring:
clinical evaluation; OR
therapeutic treatment; OR
diagnostic procedures; OR
extended length of hospital stay; OR
increased nursing care and/or monitoring.
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.637.9002
Fax: 415.600.1325
Ofc: 415.600.3739
evanspx@sutterhealth.org
I am still confused on the Palliative care exclusions you reference. There were a couple discussions about this in the past and it was never resolved (that I can see).
http://list.hcpro.com/read/messages?id=270820#270820
http://list.hcpro.com/read/messages?id=270743#270743
I am still confused as to whether palliative care and/or comfort care patients are excluded? In which scenarios? Who does this in your facility? Quality?
We continue to have a less than favorable O:E ratio while maintaining a very high CMI, high CC/MCC capture, etc. I have often wondered what the other pieces but no one in my own facility has ever been able to answer this.
I would appreciate any help/guidance. Wish I had something to help you with...
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
It is cumbersome, but perhaps ensure the 'coded' ROM/SOI scores are 'passed' correctly via software from the HIM Coding Portal to the software used to compile your overall O/E scores.
I have sometimes seen instances whereby a ROM of 3 or 4 is coded by the coder and is present in the coding software, yet the facility data compiled to report overall O/E will show a blank field for ROM/SOI for some of these claims with favorable ROM scores.
I do not know 'why' this happens and am trying to resolve this issue with the correct IT representatives .
I also repeat my belief that version 30.0 of the 3M APR/DRG grouper yields significantly lower ROM/SOI scores than the previous 3M version 29.0.
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.637.9002
Fax: 415.600.1325
Ofc: 415.600.3739
evanspx@sutterhealth.org
Kevin O'Neil, RHIT
CDI Specialist
Herrin Hospital
kevin.o'neil@sih.net
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.637.9002
Fax: 415.600.1325
Ofc: 415.600.3739
evanspx@sutterhealth.org