Quality vs SOI/ROM/CMI/reimbursement
Hi,
I have kind of asked this before but it seems increasingly interesting (confusing/frustrating)...
Have other facilities struggled with the balancing between queries that make impact (soi/rom/CMI/reimbursement- how ever your facility measures impact) and the effect on public reporting quality scores?
Anyone venture into presenting to physicians? I know in the ideal world what condition exist...exist and should be documented, but the reality is it's just not that cut and dry. I can understand physician's reluctance to document terms that they have been told are complications- because they are to a particular agency like Health Grades, even though they are not considered a complication in ICD9.
The public is never going to understand the idiosyncracies and the surgeon's will likely feel that they are more directly impacted by the Health Grades score- not the hospital's CMI or reimbursement.
I'd appreciate anyone's two cent's worth, especially personal experience of how they or their hospital has elected to address this challenging area.
I have been trying to understand surgical complication nuances but everything I may learn in the "coding world" is only one half ...it's the quality world that complicates it even more.
Thanks,
Ann
ann.donnelly@sclhs.net
I have kind of asked this before but it seems increasingly interesting (confusing/frustrating)...
Have other facilities struggled with the balancing between queries that make impact (soi/rom/CMI/reimbursement- how ever your facility measures impact) and the effect on public reporting quality scores?
Anyone venture into presenting to physicians? I know in the ideal world what condition exist...exist and should be documented, but the reality is it's just not that cut and dry. I can understand physician's reluctance to document terms that they have been told are complications- because they are to a particular agency like Health Grades, even though they are not considered a complication in ICD9.
The public is never going to understand the idiosyncracies and the surgeon's will likely feel that they are more directly impacted by the Health Grades score- not the hospital's CMI or reimbursement.
I'd appreciate anyone's two cent's worth, especially personal experience of how they or their hospital has elected to address this challenging area.
I have been trying to understand surgical complication nuances but everything I may learn in the "coding world" is only one half ...it's the quality world that complicates it even more.
Thanks,
Ann
ann.donnelly@sclhs.net
Comments
Yes, we do venture into a lot of physician education-- in groups and individually on this topic. There is a sense of urgency about it now that there's actually a congressional bill seeking release of quality info drilled down to the physician level. It's just a matter of time before the HealthGrade info becomes individualized.
Complications need to be documented clearly. That is ethical practice. That said...when a complication code is used when the physician COULD have been guided to clearly document that the 'complication' was either not clinically significant or was inherent to the procedure, that's a shame. We want to create an ACCURATE record in which the physician's true medical perspective is coded, not misunderstandings of wording.
Providers don't usually understand that when they use the word Post-op to refer to the period following surgery, it is interpreted by coding guidelines to be a link to surgery causing the condition. We discuss that with them, and then talk a lot about opportunities for risk stratification.... the fact that coding as many chronic conditions and details about the patient as possible will show the patient accurately as being at a higher mortality risk. This does not show in the data without their conscious commitment to complete documentation and accepting our help to get the wording right!
We really do work in a dynamic and critically important specialty area.
Janice Schoonhoven RN, MSN, CCDS
Clinical Documentation Integrity
Manager- PeaceHealth Oregon West Network
Like respiratory failure- not postoperative respiratory failure. Or
Aki...drug induced delirium...acute on chronic systolic hf. So I
think docs are referring to these and HISTORICALLY I was talking about
icd9 coded complications.
Sent from my iPhone
We have a balance here. We will query for SOI/ROM as well as financial impact. As I explain to my staff, we are "documentation improvement" nurses so in addition to assisting the hospitals with accurate codes for reimbursement, we also want an accurate picture of the patient and all of their diagnoses.
That being said, there are times when we proceed with caution as not to make our physicians, "query weary."
I find here when I use the APR/DRG grouper to explain to a physician how the diagnoses reflect consumption of resources and their time, I actually have a better response.
I have been doing this over 6 years and I still have to educate the ortho docs that acute blood loss anemia is not a complication rather an accurate picture of the patient's condition.
One area I am currently struggling with is the HAC, concerning bones that fracture during an orthopedic procedure. It is difficult to get the physicians to clarify if this was due to an underlying condition such as osteoarthritis as opposed to a traumatic fracture during a total hip replacement.
I once heard someone say, "if the documentation is accurate the reimbursement will follow." We try to use that as our guide.
I hope this helps.
Lisa
Lisa Romanello, RN,BSN,FNS,CCDS
Manager, Clinical Documentation Improvement
Quality and Compliance
CJW Medical Center
804-228-6527
AHIMA Approved ICD-10 CM/PCS Trainer
Angelisa.Romanello@HCAHealthcare.com