documentation and drg's课件

DOCUMENTATION AND DRGS,Documentation Challenges for the Hospital Inpatient Coder J. K. Sturgeon, C.C.S.,Developed by Patient Financial Services for the University of Texas Medical Branch at Galveston,DOCUMENTATION AND DRGs A general guide,How DRGs work How they affect the provider How the provider affects them What should be documented in order to assure the most appropriate DRG for each patient: a) generally b) specifically,Updated October 2001,DRG OVERVIEW,Basic information on DRGs What they are and how they work General documentation needs to assure the appropriate DRG for each patient,DRGs: How do they work? How do we use them?,DRGs GROUP PATIENTS WITH SIMILAR RESOURCE CONSUMPTION AND LENGTH-OF-STAY PATTERNS. THERE ARE 523 DRGs AVAILABLE. EACH DRG HAS A “RELATIVE WEIGHT.” The higher the relative weight, the greater the average resource consumption. This is used to calculate reimbursement to the hospital for DRG-based payors like Medicare (and in some states, Medicaid, Blue Cross, and others). DRGs ESTABLISH OUR CASE MIX INDEX. This is an average of the relative weights of all of the hospital admissions being evaluated. This in turn is an indicator of the severity / complexity of patient population. DRGs ARE USED FOR: determining hospital reimbursement, budgeting, managed care contracts, economic profiling, physician profiling, case management, residency program justification, and more.,DRG: DIAGNOSIS-RELATED GROUP What affects the DRG assigned for the patient?,PRINCIPAL DIAGNOSIS COMPLICATIONS CO-MORBIDITIES PRINCIPAL PROCEDURE AGE OF PATIENT DISCHARGE DISPOSITION,DEFINITIONS,Principal Diagnosis: The condition, established after study, to be chiefly responsible for causing the admission of the patient to the hospital. Complication: Any condition that arises during the hospital stay. Co-morbidity: Any pre-existing or chronic condition that the patient already has upon admission to the hospital. Principal Procedure: A procedure performed for definitive treatment rather than for exploratory or diagnostic purposes, or that was necessary to treat a complication. The principal procedure is usually related to the principal diagnosis.,PRINCIPAL DIAGNOSIS: What documentation is needed?,THIS SHOULD BE AS SPECIFIC AS POSSIBLE! ADMITTED FOR MORE THAN ONE REASON? (CHF and COPD; metastatic workup and chemotherapy) ACUTE vs. CHRONIC? (respiratory failure in an asthma patient; fluid overload in an ESRD patient; ARF in a patient with chronic renal insufficiency) UNDERLYING CAUSE? (chest pain due to C.A.D., or osteomyelitis due to Diabetic foot ulcer) UNCONFIRMED DIAGNOSIS AT DISCHARGE? A condition that is “probable”, “possible”, or treated as if it exists should be documented as such. Examples: “fever, probably due to viral respiratory infection” or “clinical sepsis, treated, not ruled out.” Physicians Billing staff needs the known diagnosis or symptoms; inpatient coders need the probable cause of those problems.,SECONDARY DIAGNOSES: What documentation is needed?,Documentation of all diagnoses that, on this admission, require: clinical evaluation, therapeutic treatment, diagnostic procedures, an extended hospital stay, or increased nursing care or monitoring (and in newborns, that have indications for future healthcare needs.) Chronic conditions: all current problems receiving care should be listed. (DM, CHF, AFib, COPD, HTN, ESRD, and so forth) Pt. receiving Meds? There should be a diagnosis associated with each medication. (e.g. “Lasix, xx/qd for control of CHF) Are lab tests ordered? When there is a known or suspected diagnosis associated with the problem, it should be documented in the patient record. The lab order slip requires the known symptom or problem, but the inpatient record can also use the suspected cause for more specific coding. (“probable UTI” or “R/O sepsis) Are X-rays ordered? Same rule as labs: the order slip must have the known problem that justifies the test, but the inpatient record can also use the suspected cause. (e.g. “suspected pneumonia”, “rule out aspiration pneumonia”, “probable CHF”, “symptoms of atelectasis”, etc.) Positive lab results? What do they mean? (e.g. low H & H is this anemia or dehydration or neither? Elevated creatinine renal insufficiency? urinary obstruction? Positive urine rbcs UTI? Kidney stone? Hematuria?),: COMPLICATIONS AND COMORBIDITIES Documentation of the following diagnoses can increase factors that determine the severity of illness & risk of mortality, and justify resources utilized for the hospital inpatient. and justify resources utilized for the hospital inpatient.,Diabetes: if documented as uncontrolled or insulin dependent COPD, emphysema Decubitus ulcer Angina Anemia due to blood loss Respiratory Failure Urinary Tract Infection Congestive Heart Failure Chronic or Acute Renal Failure Malnutrition Hyperkalemia, Hypernatremia Dehydration Pleural effusion,Pneumonia Hyponatremia, Hypovolemia Volume Overload Post-op complications: infection, graft failure, dehiscence, atelectasis, wound seroma or hematoma, ileus, urine retention Thrombocytopenia, coagulopathy Hematuria Atrial fib, flutter, heart blocks Drug/Alcohol-induced mental disorders Cirrhosis Seizure Disorder,SURGERIES AND PROCEDURES: DOCUMENTATION MUST BE SPECIFIC, COMPLETE, AND LEGIBLE!,Documentation should include who, what, when and how, and how much. What was the tissue; how was it obtained? (e.g.: lung bx. or only bronchus bx.) Was there a scope, open, or closed procedure? Did they incise, excise, cauterize, or laser ablate? Skin excision only, or also muscle / fascia / soft tissue? How large is the wound repaired or the lesion taken? “I & D” - is this “incision and drainage”, or “incision and debridement”? Or is it really “excisional debridement”? Or all of the above? Description should be as specific as possible:this determines intensity of service as well as reimbursement for both physicians and hospital billing, inpatient and DSU. Name of attending M.D. and resident need to be legible to assure that they receive credit for performing the procedure.,“SEVERITY-ADJUSTED” DRGS,determined by secondary diagnoses indicate how sick the patients really are justify greater resource consumption improve M.D.s “physician profile”,APR-DRGs: determine severity of illness / risk of mortality Each APR-DRG is split into 2 groups, with 4 grades of severity in each group,Specific documentation needs,Common diseases and disease processes; specific documentation needs for each. Symptoms that may be assigned to more appropriate DRGs with more specific documentation. Procedures that may have technical documentation requirements to assure the appropriate DRG and justify resource consumption.,COPD: asthma, emphysema, bronchitis,Acute Exacerbation. what is it? Respiratory failure, status asthmaticus, bleb, pneumonia, acute bronchitis? If pneumonia. is it bacterial? Which bug? Viral? Is it aspiration pneumonia, interstitial pneumonia? Are there other contributing pathologies? (e.g. pleural effusion, congestive heart failure, volume overload, congenital problems, or chronic diseases like fibrosis or T.B.) Acute, chronic, or both should be specified when they apply to the patient.,PNEUMONIA,The suspected cause should ALWAYS be documented. (e.g. “pneumonia due to HIV infection”, “interstitial pneumonia”, “probable Pseudomonas pneumonia”, “pneumonia likely due to Staph.”) Sputum cultures may well be negative if the patient was on outpatient antibiotics, or if the specimen or its processing were not optimal. Coders are prohibited from assuming that the bacteria in the sputum caused the pneumonia: the doctor must document the cause. Different organisms and different etiologies can result in different DRGs, severity of illness, risk of mortality, and hospital resources consumed. Unlike outpatient billing, inpatient accounts can be reimbursed for “suspected, probable, possible” diagnoses based on resources used to treat the suspected problem. If a problem is treated presumptively, it is coded unless it has been ruled out, and is reimbursed accordingly. (e.g. “pneumonia suspected due to gram negative organism” in a patient who has failed outpatient abx., or “suspected aspiration pneumonia” in a nursing home patient with dysphagia & aspiration problems from an old CVA),RESPIRATORY FAILURE,What caused the respiratory failure? This can determine the final DRG. (e.g. “respiratory failure due to acute exacerbation of COPD”, “respiratory failure due to CHF”, or “respiratory failure due to CHF and pneumonia”) The patient need not be on a ventilator; the diagnosis can be based on medical criteria including respiratory rate and arterial blood gases. “Arrest” is not synonymous with “Failure” for coding and DRG assignment. Is the “cardiorespiratory arrest” actually “respiratory failure” and “cardiac arrest”? There is no way to code, or to assign a DRG, for “Multi-Organ System Failure”. each organ system must be listed separately.,U.T.I. and “UROSEPSIS”,The diagnosis of “urosepsis” is coded and reimbursed the same as is a “U.T.I.”. it is considered to be an unspecified infection of ONLY the urinary system. “Septicemia and (or due to) a U.T.I.” should be documented as separate diagnoses. This greatly affects severity of illness, risk of mortality, and can affect the DRG and hospital reimbursement as well. “Clinical Sepsis” in the patient should always be documented, even in the absence of positive blood cultures. The symptoms from which this diagnosis is made should also be clearly documented. Related complications that may arise should be noted as well: urine retention, ARF, pyelonephritis, and the like.,HYPERTENSION,Is the hypertension benign or malignant ? “Uncontrolled” does not designate malignant hypertension. Which of the patients symptoms / systems does the hypertension affect? (Hypertensive Renal Disease, Hypertensive Heart Disease, Hypertensive Encephalopathy) What caused the hypertension? (e.g. renal artery stenosis, PCKD, chronic pyelonephritis, hyperthyroidism),RENAL FAILURE,What caused the renal failure? (e.g. diabetes, hypertension, SLE, PCKD, radio-opaque dye, other?) Is this Acute, Chronic, or Acute and Chronic failure? What does “near-ESRD” mean? It will be coded as “renal insufficiency” unless it is further specified. If a transplant patient is admitted, is it due to a complication of the transplant? What is that complication.ATN, CMV, ARF, rejection, infection, other? Related diagnoses should be documented if they are treated, evaluated or monitored, or if they extend the hospital stay. Included should be volume overload, electrolyte imbalances, urine retention, and the like.,DIABETES,Is this AODM (type II, usually adult-onset) or IDDM (type I, usually juvenile-onset)? Is the diabetes “uncontrolled” or does it have “poor control” on this admission? “Insulin-controlled” and “currently insulin-requiring” do not mean “insulin-dependent” for coding or DRG assignment. Adult-onset diabetes can still be “insulin-dependent” if it is now a permanent requirement for treatment. Is this patients cellulitis/foot ulcer/osteo/ESRD/etc. due to the diabetes? Even more critical: is it due to Diabetic neuropathy? Diabetic PVD? Diabetic nephropathy or cardiomyopathy? The above conditions should ALWAYS be documented when they apply to a particular patient.,CARDIAC CONDITIONS,Secondary diagnoses that have an origin or effect that is cardiovascular can have significant impact on severity, mortality risk, and reimbursement. Conditions on the list to the right should be documented if they are treated, or evaluated, or monitored, or if they increase hospital stay or nursing care / monitoring.,Hypertensive heart disease Post-myocardial infarction syndrome Septal thrombus. is this Acute or Chronic? Symptomatic? Old MI? Cardiomyopathieswhat type? Cause? Cardiogenic shock, shock not due to trauma V-tach, PSVT, A-fib, A-flutter, V-fib or V-flutter Congestive Heart Failure, Acute Cor Pulmonale Angina - stable, unstable, prinzmetal? Asystole, cardiac arrest, heart blocks ( Mobitz, A.V., trifascicular.be specific!) Acute Renal Failure Pulmonary embolus or infarction Myocarditis, Endocarditis Valve disorders - prolapse, insufficiency, regurgitation Rheumatic heart disease,CVA or TIA,Is this due to (or probably due to) an infarct? thrombus? embolism? hemorrhage? Is it (probably?) due to cerebral atherosclerosis, stenosis or insufficiency? Is a specific site of the obstruction known or suspected? (e.g. cerebral artery; pre-cerebral or carotid artery) If the “TIA” symptoms last more than 72 hours, is this really a CVA? Residuals still present at discharge should be clearly documented.,ARTERIAL or VENOUS OCCLUSION,What is the (suspected) cause of the occlusion? Thrombus? Atherosclerosis or plaque? Stricture or stenosis? External compression (e.g. tumor or lymphadenopathy)? Diabetic vascular disease?,HIV PATIENT,Is the reason for admission caused by the HIV infection? (e.g. “fever probably due to HIV” or “recurrent community-acquired pneumonia due to HIV”) All co-existing problems being treated, evaluated, monitored, or extending the hospital stay should be listed at least one time. (e.g. candidiasis, PCP, dehydration, cryptococcosis, diabetes, etc.) The current T-cell or CD4 count should be documented if known.,CANCER,What is the ACUTE reason for the patients admission? Pain control? Mets. workup? Surgery to primary site? Dehydration? Palliative care ONLY? Neutropenic fever or neutropenia with suspected sepsis or infection? Chemotherapy ONLY? Intractable nausea due to chemo? Post-obstructive pneumonia? Once on each admission, the primary site and all current metastatic sites being addressed on this admission should be listed. It should be specific. “mets. to bladder, colon and liver (or applicable sites)”, NOT “abdominal mets.” Is the cause of the symptoms at admission known or suspected? (e.g. “urine retention due to bladder cancer at UVJ” or “urine retention probably due to external compression from peritoneal mets.”) All secondary conditions being treated or monitored should be documented. Examples: CHF, COPD, AODM, anemia (blood loss?), electrolyte imbalances, infections, coagulopathies, and so forth.,G. I. BLEED,Can the bleeding be more specifically described as melena, hematochezia, or hematemesis? If a source of the bleed is known or suspected, inclusion in the discharge progress note would be most helpful. Endoscopy notes should include the cause of the bleed as well as the physical findings. Does “gastric ulcer, no active bleed” mean that the ulcer is NOT the cause of the bleed? Or that despite no current bleeding, we presume the ulcer to be the cause? If workup reveals gastritis, an erythematous polyp, internal hemorrhoids and a healing gastric ulcer: A) is a specific one of these suspected to be the cause of the bleed? B) might any of them be the cause? C) are none of them severe enough to be causing the bleed, and the patient needs further workup? Failure to have the cause, or suspected cause, documented can affect DRG assignment, reimbursement to the hospital, and severity of illness indicators for the patient.,OBSTETRICS,What is the ACUTE reason for admission. pre-eclampsia? Gestational diabetes? Preterm labor? Dehydration? Is the reason for admission unrelated to the pregnancy? (e.g.: “patient with broken ankle for ORIF, 18 wk. incidental pregnancy” or “patient with second degree burns to ankle, 22 wk. pregnancy unaffected by injury.”) It should be specified when diagnoses have their origin in the postpartum period. (e.g. “postpartum uterine atony”or “postpartum” fever) These are coded, and reimbursed, differently than if they are not specified as ante- or post-partum. If this is a preterm or postmature delivery, documentation should state this specifically as such rather than just documenting estimated weeks. Did the patient have insufficient prenatal care? Is she a high-risk patient? All diagnoses that are monitored / evaluated / treated should be documented. (e.g. endometritis, venereal diseases, pre-eclampsia, all anemias, UTI, other infections, placenta problems - retained, abruptio, etc., diabetes and hypertension -gestational or chronic?). Is there a diagnosis associated with “+GBBS” or “+ WBCs in urine”? Post-operative problems should be documented as well. (e.g. wound dehiscence, hematoma, seroma, or infection; spinal headache, ileus or atelectasis),NEONATES,Is the infant Preterm? Is this Extreme Prematurity? If baby has respiratory problems, specify whether they are due to: HMD, RDS, TTN, apnea (of prematurity?), meconium aspiration syndrome, pneumonia, pneumothorax, anemia, hypoplastic lung, and so forth. Document all that apply. Is the baby hypoglycemic? Hypovolemic? Hypotensive? (“hypoperfusion” cannot be coded a specific diagnosis should be listed if possible) Hypocalcemic? Other transient electrolyte imbalances? Why are we “ruling-out sepsis”? Maternal chorio? Symptomatic baby? Did we rule it out? If not, “clinical sepsis” can be documented if sepsis is presumed even in the absence of positive blood cultures. If it isnt sepsis, the suspected cause of the babys symptoms should be documented instead. Does any specific diagnosis extend the stay? The reason should be noted. Are maternal drugs or meds. affecting the infant? How? Are there any congenital infections, or suspected infections? Diagnosis should be specific pneumonia, conjunctivitis, viral syndrome, etc. Heart murmur. insignificant or functional? Probable PDA? Or does it need follow-up because it is still undiagnosed at discharge? Diagnoses that need follow up after discharge, should be listed individually on the nursery discharge summary at line 6 “Needs follow-up for:”,FEVER,Is the cause of the fever known, or suspected, at discharge? If so, it is best to have this documented in the discharge progress note and discharge summary. For example: “Fever, probabl