mortality rate exclusions?

katysuegood@gmail.comkatysuegood@gmail.com
in CDI Talk Archive
This topic may be a little out of the CDI spectrum, but I’m hoping someone has some knowledge on this.

It is my understanding that in the past, patients documented as being on palliative care were excluded from certain quality measures. However, this changed earlier this year. Now patients receiving “palliative care” are no longer excluded but the documentation of “comfort care” may exclude the patient from core measure criteria?
I want to make sure I am understanding this correctly and would appreciate any feedback. I am assuming this has to be manually abstracted because as far as coding goes, there is only one code for palliative care (V66.7) and no differentiation for Comfort Care. It is my understanding that the coding of V66.7 can exclude the case from some mortality rate calculations but not core measures? True? I know there was advice given on the ACDIS site early this year advising CDI to query for the term “comfort care only” if applicable. Are you doing this?

Anyone know anything about this?

I probably have more questions but I don’t even know where to begin…


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

Comments

  • lprescottlprescott
    edited May 2016
    katy, we were recently given this information. And have heard this from several resources. I am not sure about exclusion from core measures criteria but we were told these patients would not be ecluded from mortality data. We have given the physicians education about palleative/comfort care documentation and have also given the coding staff education to assure this is included in secondary diagnoses if documented.

    They also refer all deaths to the CDS staff for a second level review to assure we have captured any query opportunities to include palleative care.
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    Which patients will be excluded from mortality data? Palliative care AND Comfort Care? Or just Comfort care? And based on what? If it applies to both Palliative care and Comfort care, we have our V code for that but there is nothing to differentiate CC.
    Also, it seems like just being on PC service would be a weird reason to exclude as they are often receiving curative treatment as well.

    I'm confused....

    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

  • lprescottlprescott
    You know katy I am not sure. My understanding is that the rational for removing is that they are expected to die so including in our mortality statistics makes no sense. The code will not change our DRG not a CC but the presence of the code does indicate this patient's main treatment was directed towards the process of comfortable death. Also your mortality data is affected by patients that die post discharge (I am unsure exactly within what time frame). So if we discharge to hospice care there death in the recent post discharge time period should not have negative impact if the code for comfort or palleative care is present. this effects physician quality scores as well. I know enough to be dangerous on this topic so please seek a better resource!
    Laurie L. Prescott RN, MSN CCDS
    lprescott@morehead.org
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    Yes, I identify with you "I know just enough to be dangerous" sentiment. I feel this way about soooo many things that are loosely connected to CDI.

    We have an unusually high O/E ratio for mortality. We have a very high CMI, and a high CC/MCC capture rate. I personally review each death record extensively and they also go through a quality review and we have yet to figure out what the issue is.
    I got to thinking about whether exclusions could be the issue but as of yet no one from my facility has been able to give me any concrete answers as to when cases are excluded and how this is determined.I know its not really my problem but...

    Hmmm.....

    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


  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited May 2016
    Hi, Katy

    I am sure you are probably aware of these, but RE: a high O/E ratio - Have had great success bringing O/E to 1.0 or less by using query methodology for:

    Acute Renal Failure
    Sepsis
    Type and Acuity of CHF


    Just a thought....584.9 is probably one of our most common secondary conditions and this can positively impact SOI/ROM on many cases lacking other conditions.

    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


  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    Thanks Paul,
    What is interesting is that the hospital overall had a high CMI (almost 2) and a high CC/MCC capture rate. We are high-outliers for both sepsis and CC/MCC capture rate per our PEPPER data. I'm fairly confident about sepsis and CHF capture. I'm not so sure about ARF, I need to look into that.
    Thanks for the insight.


    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


    -----Original Message-----
    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Wednesday, November 28, 2012 4:01 PM
    To: Kathryn Good
    Subject: RE: RE:[cdi_talk] re:mortality rate exclusions?

    Hi, Katy

    I am sure you are probably aware of these, but RE: a high O/E ratio - Have had great success bringing O/E to 1.0 or less by using query methodology for:

    Acute Renal Failure
    Sepsis
    Type and Acuity of CHF


    Just a thought....584.9 is probably one of our most common secondary conditions and this can positively impact SOI/ROM on many cases lacking other conditions.

    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


  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited May 2016
    Thanks, Katy: I agree with your thoughts. Generally, one would 'expect' a 'good' Observed/Expected Ratio concurrent with a high CMI and high CC/MCC capture rate. (I know ARP-DRG and MS-DRG 'not the same', but in general, a system leading to better capture of etiology, manifestation, acuity, will lead to improvement in both systems.

    Do you have this formula for O/E computation: (We use MIDAS DataVision)

    Acute Care Admission Mortality Ratio (Observed/Expected) (1 measure)

    Definition: Acute Care Admissions Mortality ratio is the APR-DRG risk-adjusted ratio of observed/expected deaths for acute inpatient admissions based on the MIDAS DataVision benchmark. Results are compared to the MIDAS “universe” standardized O/E mortality ratio (1.0). A ratio of 1.0 means that a hospital’s mortality is average in comparison to the national MIDAS Comparative Database (CDB) comprising more than 600 hospitals. Below 1.0 means that the mortality rate is lower than the average performance of the comparative group and above 1.0 means that the hospital’s mortality is higher than the average performance of the comparative group/database.
    Numerator: Observed deaths.
    Denominator: Expected deaths.
    Measurement Calculation: Numerator divided by denominator.
    Data Source: MIDAS DataVision Hospital APR-DRG Ranking Report.
    Benchmark Goal Source: MIDAS DataVision web application comparison population for the standardized mortality ratio benchmark of 1.0. This is based on the concurrent period MIDAS comparative database of approximately 100,000,000 encounters from more than 600 hospitals nationally.

    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

  • glgibbons@lexhealth.orgglgibbons@lexhealth.org
    edited May 2016
    I think I just hit the wrong button, so I don't know if my last post was lost or what, so I will start over.

    We have been extensively reviewing the CMS Pneumonia mortality rates of publicly reported data and what excludes a patient from being reported. What I have found out is:
    Excluded: 1. Those who were discharged the same day of admission or day after, and didn't die or get transferred.
    2. Those who were transferred in from an acute care facility or the VA. The death is attributed to the hospital that they were orginially admitted.
    3. Those who were enrolled in a Medicare Hospice program any time in the 12 months prior to the hospitalization.
    4. Those who discharged AMA.
    5. Also, pts who have more than one admission in a year, one visit per year is randomly chosen for INCLUSION.

    Also, verify which diagnosis codes are included and excluded per DRG. If the pdx is one of the excluded ones, then that pt will be excluded from the mortality data too.

    I hope this helps.

    Gail Gibbons, RN, BSN, CCS
    glgibbons@lexhealth.org
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