Guidance related to mortality

Hello all,
Our CMO is asking me to help her understand the relationship with a patient admitted with mets to the spine who ends up dying in the facility.

The patient was admitted with mets to the spine with cord compression.
She has a history of Stage 4 Lung cancer
Her condition declined during the stay and she passed away while inpatient.

Hospice was consulted but she died prior to their arrival.

The case was final billed as a MS-DRG 542 with the mets to the spine being the principal diagnosis.

Apparently, this creates a poor mortality rating for our orthopedic service line.
Our CMO is struggling to understand why the cancer was not the principal diagnosis so as to move this out of the ortho DRG. I have done my best to explain to her that the mets to the spine was the primary reason for presenting to the facility as well as the Stage 4 Lung cancer was not treated during this admission.

I believe a more timely hospice consult would have helped to solve this dilemma.

I am seeking any other advice, opinions or ideas on how I can explain this concept more accurately.

I appreciate any thoughts you might have.
Thank you,
Lisa



Lisa Romanello,RN,BSN,FNS,CCDS
Manager, Clinical Documentation Improvement Specialist
CJW Medical Center
Quality and Compliance
804-228-6527

Comments

  • edited May 2016
    What was focus of treatment on, the mets to spine or the primary cancer? Was patient a DNR? Comfort measures?

    Sue
  • She was a DNR. There was no order for comfort care. The focus of treatment was all based on the mets. They attempted a few radiation treatments and then ceased as she could not tolerate the treatments.

  • edited May 2016
    Can you show her the coding guidelines for neoplasm? Also maybe coding clinics related to such. Reading may help understand it better. Just a thought :)


    Sue


  • Thank you for that idea.
    I will try it.
    Lisa

  • edited May 2016
    Hi Lisa!

    Ref. C. Clinic 3rd Qrtr. 1999. Pathological fx of vertebrae with met carcinoma. Pt. with spinal cord injury/compression due to met ca. In order to estabish the correct principal diagnosis, would need to know if the patient chart reflected the thrust of treatment was for the primary or secondary ca or the cord compression. If the patient had a bone biopsy, kyphoplasty, vertebroplasty than it will change the DRG. Not sure why the patient was admitted to orthopedics unless they planned to do a procedure for the cord compression/fracture. Hope this info is helpful.

    Jolene File,RHIT,CCS,CPC-H,CCDS
    Documentation Improvement Specialist-Coder
    Hays Medical Center
    jolene.file@haysmed.com

    IMPORTANT: This communication contains information from Hays Medical Center which may be confidential and privileged. If it appears that the communication was addressed or sent to you in error, you may not use or copy this communication or any information contained therein, and you may not disclose this communication or the information contained therein to anyone else. In such circumstances, please notify me immediately by reply email or by telephone. Thank you.
  • Lisa,

    Separate from the pdx question, what system do you have access to ... is in use at your facility ... to determine expected mortality risk? Do you have access to APR/DRG? University Healthsystem Consortium? something else?

    Really, the CMO's concern should be what was the ROM for this patient ... were all of the relevant factors present with this patient documented to provide a strong expected mortality?

    In my opinion, the strongest way to examine mortality is an observed/expected index, ie, risk adjusted perspective. With access to a tool for expected mortality you can demonstrate how this case (possibly) does NOT hurt.

    Don

  • Thank you Don for your help.
    Lisa

  • edited May 2016
    We started trying work on our mortality charts about 4 1/2 years ago but eventually it was a full time endeavor. I am now completely dedicated to mortality reviews at my facility and have been for 3 years. I review for coding and DRG assignment, quality-of-care, and do risk adjustment calculations on each patient.

    Based on the information you provided, it does sound like the chart has been coded accurately.

    We follow the UHC Risk Adjustment Models for our mortality patients. Under their methodology, some v codes carry significant weight in risk adjustment--such as the palliative care and DNR codes. However, 3M Consultants have told me that the DNR v code has no impact on the SOI/ROM in their calculations and methodology.

    In Risk Adjustment, POA status of your diagnoses may also be significant. For UHC, only diagnoses that are POA-Y "count" (except the DNR v code, which can be POA-N). It is important to understand how sick the patient was when they were admitted; conditions that developed or were acquired during the hospitalization do not factor into some methodologies like UHC's. Thus, attention to accurate POA assignment is warranted. Also, ensure the dates on your procedure codes are correct, particularly for initiation of mechanical ventilation.

    If your facility gets transfers from other hospitals or nursing homes, ensure that data is correct as this can aid in your profiling as well.

    I do agree with what was said below. You do want to look at your Observed/Expected ratio. Also, it is important to know what the mean expected rate is for each MS-DRG and see how far above or below you are in relationship to that mean.

    Pam Florence, RN


  • edited May 2016
    Pam Florence, would you share your direct email information? I would like to communicate with you.

    Thanks Tiffany Andras LPN CDI
    Thibodaux Regional Medical Center
    602 North Acadia Road
    Thibodaux, Louisiana 70301
    985-493-4593

  • edited May 2016
    My contact information is below.


    Pam Florence, RN
    Clinical Documentation Specialist
    UK HealthCare
    Phone: (859) 323-1236
    Pager: (859) 330-8608
    E-mail: paflor2@uky.edu



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