Rachel Mack, RN, MSN, CCDS, CDIP

Rachel Mack is a CDI Specialist for SCL Health where she performs current chart reviews and audits. The focus of her work is on identifying missed opportunities to obtain an accurate and complete record for each patient. Rachel has nursing experience in CVICU, ICU, and home health and has worked in Clinical Documentation Improvement as a CDI Specialist, CDI Educator, and CDI Consultant. She has written various articles for the VBPmonitor and ICD-10monitor and has assisted in creating CDI training materials. She was also a presenter at the 2015 ACDIS conference.

Tuesday, 12 April 2016 04:49

CDI and Hospital Readmissions

r mack“Do you ever have déjà vu?” –Bill Murray, Groundhog Day

Let me describe an awkward situation – it’s a Monday, and you are reviewing a patient who has discharge orders already in place. You have queried, obtained a response, and had a great interaction with a physician throughout this patient’s stay. The patient looks great – well, as great as can be expected for being chronically ill. You arrive to work on Tuesday morning and see that the patient is still here…but wait! He was discharged at 5:06 p.m. yesterday and readmitted at 2:13 a.m. today. So now you are reviewing an entirely new stay.

This is what is referred to in the industry as a “CDI (clinical documentation improvement) nightmare.” CDI specialists often refer to these patients as “frequent flyers,” and what used to result in a simple eye-roll is now a serious concern. The repercussions of readmissions can weigh heavily on hospitals, and often there is not much we can do to prevent them. However, a strong CDI and coding program can have an impact on the risk adjustment associated with readmissions.

What is a Readmission?

Per the CDI Pocket Guide published this year, a readmission is defined as “a patient who is admitted for any reason to the same or another acute-care hospital within 30 days of discharge. Certain readmissions are exempt, such as planned chemotherapy or rehabilitation.”

The U.S. Department of Health and Human Services (HHS) announced in January 2015 a new set of goals and a timeline for tying Medicare payments to quality or value through alternative payment models. Included in these “alternative payment models” for inpatient stays is the Hospital Readmission Reduction Program (HRRP). The Centers for Medicare & Medicaid Services (CMS) has set a goal of tying 85 percent of all traditional Medicare payments to quality or value by 2016, and 90 percent by 2018, through programs like HRRP and Hospital Value-Based Purchasing (VBP).

The penalties associated with readmissions are much more severe than those of other pay-for-performance (P4P) programs. Hospitals may now lose up to 3 percent of reimbursement moving forward, depending on their readmission performance. The HRRP imposes these penalties on Medicare patients admitted with the following diagnoses: acute MI, heart failure, pneumonia, COPD, and elective hip or knee replacement (s/p CABG will be coming in 2017).

So, what does performance entail? How does CMS know how well your hospital is doing? Put simply, it compares your hospital to other hospitals across the country. If your hospital exceeds the “risk-adjusted national readmission rate,” then you will be penalized, and, per the CDI Pocket Guide, “for FY 2015, Medicare estimates that about 78 percent of hospitals were penalized an aggregate total of $428 million.”. Not only that, but CMS estimates that about one in five Medicare patients will experience a readmission.

Exclusions to HRRP

Fortunately, there are some exclusions to the HRRP program – these include admission for planned chemotherapy or a pre-planned surgery, rehabilitation stays, neonates, cystic fibrosis patients, palliative care patients, many/most HIV DRGs, and patients that leave against medical advice (AMA). As I have discussed in previous articles, it has never been more important to establish the correct principal diagnosis for a patient (for a multitude of reasons, not just HRRP!) and to make sure we are documenting if they are noncompliant or leave AMA.

I’m just a CDI Specialist – What can I Do?

“Once again the severity of illness based on comorbid conditions influences the risk adjustment,” the CDI Pocket Guide reads. “Sicker patients are expected to have higher readmission rates, so hospitals with a patient population reflecting higher severity will have their readmission rate adjusted downward and therefore are less likely to be penalized.”

What does this mean for CDI? It means that we are already assisting in identifying the best severity scores for our patients, indicating that we are already helping influence our hospital’s overall risk adjustment scores. There are several diagnoses that, if we can get them established in the record and final-coded, can and will affect risk adjustment. They are different for every readmission diagnosis, as each such diagnosis (for example, heart failure) has numerous diagnoses that influence the risk adjustment score. But several of them are similar across the board. Here are a few:

  • Protein-calorie malnutrition
  • Cardiorespiratory failure or shock
  • Sepsis/septicemia/shock
  • Dementia and other specified brain disorders
  • CHF
  • Stroke
  • Hemiplegia, paraplegia, paralysis, functional disability
  • Pneumonia
  • ESRD or dialysis, renal failure
  • Drug/alcohol abuse, dependence, or psychosis
  • Decubitus ulcers or chronic skin ulcers

This is just a small sample of some of the diagnoses that affect risk adjustment. CDI specialists are already identifying several of these throughout chart review – and this is a good thing! If we can get these diagnoses established in the record – regardless of “usual” CDI impact – this can help adjust your hospital’s risk scores in the positive direction.

What about Noncompliance?

Readers may be thinking, “okay, great, I can do all of this and help my hospital – but what if the patient is noncompliant?” Unfortunately, there is not much that we can directly do about noncompliance. Many patients are noncompliant due to financial burdens and limited health literacy skills.

However, if a patient is noncompliant, this needs to be documented in the record and established in final coding. Per ACDIS, “CDI specialists can assist facilities by identifying when noncompliance plays a role in the readmission. By securing the necessary documentation to allow coders to report [noncompliance], hospitals can use this documentation and coded data to help prevent or appeal denials … (and) if [it] is reported in the top nine diagnosis codes when it is transmitted on the UB-04, (it allows) the payor to have the knowledge that patient noncompliance may have contributed to the readmission. “As we already mentioned above, if your patient leaves AMA, it is imperative to have this documented, as this will exclude the patient from readmission calculations.

In Conclusion

The numbers don’t lie – patients who are sicker, with more chronic conditions, have an increased risk of readmission. It’s that simple. As a CDI specialist, it’s easy to feel powerless when it comes to readmissions. However, during your chart review you likely already are identifying ways to improve your patient’s severity of illness and risk of mortality (SOI & ROM) scores. Work with your quality team to identify all diagnoses that, if established in the record, can best benefit a hospital’s risk adjustment ratings.

About the Author

Rachel Mack is a CDI specialist for SCL Health, where she performs current chart reviews and audits. The focus of her work is on identifying missed opportunities to obtain an accurate and complete record for each patient. Rachel has nursing experience in CVICU, ICU, and home health, and has worked in clinical documentation improvement as a CDI specialist, CDI educator, and CDI consultant. She has written various articles for VBPmonitor and ICD-10monitor and has assisted in creating CDI training materials. She was also a presenter at the 2015 ACDIS conference.

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“Change before you have to.” –Jack Welch

Everyone reading this knows that healthcare is changing, which means that clinical documentation improvement (CDI) is also changing – as in, constantly changing. Actually, it’s constantly changing to the degree that it is becoming quite difficult to keep up at all times. CDI used to be about CC/MCC capture. Then it became about telling the patient’s story and assigning the best severity score to every patient, every time. The next level of CDI is accurately assisting with the correct documentation of quality measures and ensuring that your hospital doesn’t succumb to penalties associated with poor outcome measures.

What is an Outcome Measure?

The Agency for Healthcare Research and Quality (AHRQ) defines a clinical outcome as “a health state of a patient resulting from healthcare.” For more information regarding Outcome Measures please visit their website at http://www.qualitymeasures.ahrq.gov/tutorial/HealthOutcomeMeasure.aspx.

This sounds simple enough. However, two patients experiencing the same disease process could have dramatically different outcomes based on numerous factors. We already know that patients with diabetes, obesity, CHF, and COPD are likely to have worse outcomes when compared to patients that do not have these comorbid conditions. This can be taken into account by adjusting for risk factors, so patients are compared “apples to apples” and not “apples to doughnuts.”

Therefore, an outcome measure is a quantification of all outcomes that the Centers for Medicare & Medicaid Services (CMS) is now using to adjust payments hospitals receive for the care they provide. If they perform well on certain outcome measures, they earn appropriate payment, and if they perform poorly they will earn less.

Hospital-Acquired Conditions (HACs) Reduction Program

A hospital-acquired condition (HAC) is a condition a patient develops during a hospital stay that was not present on admission (POA) and that leads to poorer outcomes and longer lengths of stay. Please note that this program is different from the HAC program started by CMS in 2008.

On Oct. 1, 2015, Medicare started penalizing hospitals that fall into the poorest-performing groups for certain HAC measures. The penalty is a 1-percent rate reduction of their total Medicare DRG payments and includes the following outcome measure domains:

  • Domain 1: AHRQ PSI-90 Measure, composite of eight patient safety measures
  • Domain 2: Measures included CDC-defined central-line associated blood stream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), and colon and abdominal hysterectomy surgical site infections (SSIs).

For the 2016 fiscal year, the weight of Domain 1 is 25 percent and the weight of Domain 2 is 75 percent. For 2017 and 2018, Domain 1 is decreasing in weight to 15 percent and Domain 2 is increasing in weight to 85 percent.

It is easy to see why these new rules are gaining so much attention – in 2014 the total outcome measures were only weighted at 10 percent. The overall outcome measure weighting is increasing from 30 percent in 2015 to 40 percent for 2016.

A 1-percent cut may not seem like a large financial penalty to hospitals. However, this can be very detrimental to a hospital’s bottom line. If a hospital system has, on average, 15,000 Medicare discharges per year and its average MS-DRG payment is $8,000, this equates to $120,000,000. If this hospital were to perform poorly when it came to HACs, that penalty would be $1.2 million, and it likely will worsen in the future.

Focus on CLABSI

A central line is a catheter that terminates at or close to the heart in one of great vessels that is used for infusion, withdrawal of blood, or hemodynamic monitoring. Per the Centers for Disease Control and Prevention (CDC), the following are considered great vessels: aorta, pulmonary artery, superior and inferior vena cava, brachiocephalic veins, internal jugular veins, subclavian veins, external iliac and common iliac veins, femoral veins, and the umbilical artery/vein in neonates.


The CDC defines central line-associated bloodstream infection (CLABSI) as the following:

A laboratory-confirmed bloodstream infection (LCBI) where central line (CL) or umbilical catheter (UC) was in place for > 2 calendar days on the date of event with the day of device placement being Day 1 AND a CL or UC was in place on the date of event or the day before. If a CL or UC was in place for > 2 calendar days and then removed, the date of event of the LCBI must be the day of discontinuation or the next day. If the patient is admitted or transferred into a facility with an implanted central line (port) in place, and that is the patient’s only central line, day of first access in an inpatient location is considered Day 1. “Access” is defined as line placement, infusion or withdrawal through the line. Such lines continue to be eligible for CLABSI once they are accessed until they are either discontinued or the day after patient discharged (as per the Transfer Rule). Note that the “de-access” of a port does not result in the patient’s removal from CLABSI surveillance.

An important takeaway from the definition of CLABSI is the concept of present-on-admission (POA) conditions. If the patient has a CLABSI that is POA, this is not considered a hospital-acquired infection and is not reported to the CDC. The other important takeaway for CLABSI is it is not a physician’s opinion. The patient must have a positive blood culture that is laboratory-confirmed.

Please visit the CDC’s CLABSI website for more information or any clarification – there are many rules to CLABSI and they are important to understand: http://www.cdc.gov/nhsn/PDFs/pscManual/4PSC_CLABScurrent.pdf.

CLABSI and CDI – Getting it Right

As I have mentioned in previous articles, one of the most essential current and future roles of a CDI specialist is establishing POA status for numerous conditions. CLABSI certainly represents one of these conditions. Many HACs are reported as HACs simply due to poor documentation.

For example, if your patient is admitted with a central line – and there is no documentation of this in the patient’s H&P – this needs to be established. One of the most common documentation errors I see when reviewing records is no mention of preexisting lines (central, Foley, etc.), but it is scattered throughout nursing documentation and head-to-toe assessments. Or even worse, it is not mentioned by a provider until hospital day No. 2 or No. 3, making it look like the line was not present on admission.

Citing the same example, if there is no documentation of the line by a provider until hospital day No. 3, but we check blood cultures and they come back positive, this could result in a CLABSI being reported. This is inaccurate, and likely the infection was POA and simply needs to be queried for by the CDI specialist.

Remember, a coder is unable to code most diagnoses from RN documentation; they must be documented by the physician. So CDI specialists need to vigilant in identifying this in the record and querying if need be. Providers need to continue answering these queries and updating their daily progress notes and discharge summaries to reflect all diagnoses for which a patient is receiving care.

The bottom line is this – hospitals are expected to provide optimal care for patients. Providing that optimal care and documenting it well results in more accurate severity scores, accurate morbidity and mortality scoring, and accurate reimbursement for hospitals. A difficult aspect of caring for patients in this new world of healthcare is ensuring that the documentation aligns with care and treatment provided. Every single CLABSI that has been improperly identified due to deficient documentation that is corrected by the healthcare team and not coded to that patient’s record is a “win” for the hospital. Every one of these “wins” contributes to your hospital’s good standing in reported quality measures and minimizes the prospects of being included in the lowest-performing groups for the HAC reduction program.

About the Author

Rachel Mack is a senior healthcare consultant for Panacea Healthcare Solutions, where she performs clinical documentation and quality chart audits that focus on identifying missed opportunities to obtain an accurate and complete record for each patient.  Rachel has nursing experience in CVICU, ICU, and home health, and has worked in clinical documentation improvement as a CDI specialist and CDI educator. She has written various articles and assisted in creating CDI training materials. She was also a presenter at the 2015 ACDIS conference.

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“Do or do not. There is no ‘try.’” –Yoda

Dear Oct. 1, 2015 – are you trying to kill us? As all of you know, implementation of the ICD-10-CM and PCS coding guidelines is set to take place in the U.S. on this date. What you may not know is that there is another pay-for-performance (P4P) initiative that takes effect Oct. 1 – the Hospital-Acquired Condition (HAC) Reduction Program. Per the Centers for Medicare & Medicaid Services (CMS) website:


“Section 3008 of the 2010 Patient Protection and Affordable Care Act (PPACA) established the HAC Reduction Program to encourage hospitals to reduce HACs. HACs are a group of reasonably preventable conditions that patients did not have upon admission to a hospital, but which developed during the hospital stay. Hospital performance under the HAC Reduction Program is determined based on a hospital’s Total HAC Score, which can range from 1 to 10. The higher a hospital’s Total HAC Score, the worse the hospital performed under the HAC Reduction Program. Hospitals are given an opportunity to review their data and request a recalculation of their scores if they believe an error in the score calculation has occurred. Effective beginning FY 2015, the law requires the Secretary of the Department of Health and Human Services to reduce payments to hospitals that rank in the quartile of hospitals with the highest total HAC Scores by 1 percent.”


The target HACs include claims-based PSI (patient safety indicator) No. 90 weighted at 35 percent and two CDC abstraction measures weighted at 65 percent:

PSI 90:

  • Pressure ulcer – Stage 3 and 4 (or unstageable)
  • Iatrogenic pneumothorax
  • Central venous catheter-related blood stream infection
  • Post-op hip fracture
  • Perioperative pulmonary embolism or DVT
  • Post-op sepsis
  • Post-op wound dehiscence
  • Accidental puncture or laceration

Two CDC Abstraction Measures:

  • CLABSI (central line-associated blood stream infection)
  • CAUTI (catheter-associated UTI)

CMS estimates that 807 hospitals would be subject to the 1-percent reduction in 2016. Why are HACs so difficult to manage? What muddies the waters? Let’s take a look at a typical documentation scenario that may cause a condition to be coded as a HAC.

Typical Situation – Uncharted Territory

The below table contains typical documentation that clinical documentation improvement (CDI) specialists and coders come across. We’ll use catheter-associated UTI (CAUTI) as our HAC example:

6/1/15 History and Physical:

“Acute Renal Failure on CKD stage 3. IV fluid resuscitation started, 1st liter in. Check UA.” –Dr. Smith

6/2/15 MD Progress Note:

“AKI on CKD. Creatinine 2.6—1.8 today. Continue treatment. UTI, started Rocephin. Cultures pending, will adjust accordingly.” –Dr. Jones

6/2/15 RN Progress Note:

“Indwelling Foley cath, per wife has been in 2 weeks. Removed per Dr. Smith, new Foley placed.” –Rachel, RN

6/4/15 Discharge Summary:

“AKI on CKD, creatinine back to baseline. UTI 2/2 to Foley cath, cultures grew Klebsiella, started on Ceftin.” –Dr. Carter

Read the above series of events and documentation carefully. Based on the above documentation, if no query was sent or a query was sent with no response from the provider, the coder would have no choice but to code this as a CAUTI and put “no” for present on admission. This series of events indicates to Medicare that this hospital caused this patient to develop a CAUTI (HAC) due to poor care.


The above situation happens more than we realize, and it is a tragedy. Any reviewer can see that the patient’s UTI was likely due to the indwelling Foley catheter he had present on admission. But if this is not documented or clarified well enough in the record, then your hospital is at risk of becoming one of the low-performing hospitals Medicare is targeting.

What Does this Mean for Coders and CDI Specialists?

Essentially, this means doing what you’ve always done. It also means sending POA queries much more aggressively than you already are.

As CDI programs become more established, I’ve noticed that queries start to evolve. Yes, you’re still asking about acute respiratory failure, malnutrition, and CHF specificity. These topics (and the requirement that specificity be in place in order to be as accurate as possible) will likely never go away. But what I have been noticing is that these types of queries decrease as more high-level queries are sent.

In my personal experience, during my first six months to one year of CDI work, maybe 5-10 percent of my queries were simple POA (present on admission) queries. As my providers became more savvy – and, let’s face it, wanted me to leave them alone – their overall documentation improved. Then the queries I sent became much more POA and cause-and-effect-focused. This will continue to be the case in ICD-10, but with increased importance. Per Dr. Richard Pinson and Cynthia Tang, “the importance of documenting or clarifying the POA status of such conditions to avoid improper classification as a HAC cannot be over-emphasized.”

If you are in doubt for a moment that the clarification of POA status is in the record is lacking for a possible HAC event – query. Believe me, you would so much rather take the additional 10 minutes to prepare and send the query than contribute to your hospital being in the lowest-performing quartile for HACs. Ouch.

As for coders, if you are coding a record and you are getting ready to put an “N” as the POA status of any HACs, stop. Re-review your documentation, and if need be, send a query. In my personal experience, most coders tend to shy away from queries unless they absolutely cannot code a record. You should view HAC events the same way. Your hospital is counting on you to clarify.

Final Thoughts: Educate, Educate, Educate!

We know (or hope!) that most documentation programs are already in full swing as they pertain to educating physicians on ICD-10. Help these providers out in any way that you can and include at least one slide about the new HAC Reduction Program as well. Most providers want to do what’s right and document the best they can to reflect the fantastic care they provide. The more they know, the better shape they will be in for the future.

The Centers for Disease Control and Prevention’s (CDC’s) rules for classifying what exactly constitutes a CAUTI are challenging, and I will not be discussing those complicated criteria here. If you would like more information about these rules, please go online to http://www.cdc.gov/nhsn/PDFs/pscManual/7pscCAUTIcurrent.pdf.The absolute best practice that any provider can employ is simply to do the following:

  1. Document if a patient’s infection, PSI 90 measure, or HAC measure is POA or not.
  2. Document if that infection or PSI 90 measure is due to a device (Foley catheter, PICC, etc.).
  3. Document a cause-and-effect relationship with the actual germ for the infection, if known. If your patient’s cultures grow Klebsiella and the only place this is documented is in the culture pathology, a coder cannot assume any significance of that culture. As a provider, you must document “Klebsiella UTI due to indwelling Foley catheter, present on admission.”

Oct. 1 is right around the corner. With sound documentation practices, your hospital can survive all of the P4P initiatives. 

About the Author

Rachel Mack is a senior healthcare consultant for Panacea Healthcare Solutions, where she performs clinical documentation and quality chart audits that focus on identifying missed opportunities to obtain an accurate and complete record for each patient. Rachel has nursing experience in CVICU, ICU, and home health, and has worked in clinical documentation improvement as a CDI specialist and CDI educator. She has written various articles and assisted in creating CDI training materials. She was also a presenter at the 2015 ACDIS conference.

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r mackOh, sepsis. For years it was frequently under-documented, and now many providers believe it to be over-documented. In coding and clinical documentation improvement (CDI), sepsis is a frequent thorn in the side of chart review – was it POA? What is the source? Is it the Foley? Oh, and it’s documented in every note except the discharge summary – Dear Provider, can you please address this?

In 2002, sepsis received international fame associated with the initiation of the Surviving Sepsis Campaign (SSC), which resulted in the publication of a new standard of care for treating sepsis worldwide. The goal of this campaign was to reduce mortality from sepsis by 25 percent in five years. In 2010 the SSC revealed that a 15,000 patient data set had a 20-percent relative risk reduction when associated with sepsis bundle compliance. Not too shabby.

Regardless of what your personal opinions of sepsis might be, the fact remains that it will become a new Centers for Medicare & Medicaid Services (CMS) core measure for 2016. Is your hospital ready?

Sepsis – A Definition

First, what is sepsis? Though the exact definition is debated, the Sepsis Alliance defines it as “the body’s overwhelming and life-threatening response to infection, which can lead to tissue damage, organ failure, and death.” More simply, sepsis is systemic inflammatory response syndrome (SIRS) due to an infection. To meet criteria for SIRS, patients must meet at least two of the following criteria:

  • Fever (temperature  greater than 101.0°F) or hypothermia (temperature less than 96.8°F)
  • WBC greater than 12,000 or less than 4,000 or bands less than 10 percent
  • Tachycardia (heart rate greater than 90) not easily explained by another co-existing condition
  • Tachypnea ( respiration rate greater than 20) not easily explained by another co-existing condition

Other diagnostic SIRS criteria include but are not limited to:

  • Lactate greater than 2.0
  • Elevated procalcitonin
  • Elevated C-reactive protein
  • Altered mental status
  • Mottling of the skin
  • Hypotension

Seems pretty straightforward, right? Not exactly. Coders, CDI specialists, and physicians know how difficult it can be to diagnose sepsis. Also, notice that “positive blood cultures” are not part of the diagnostic criteria. This is a difficult concept for physicians – when blood cultures come back negative but we are treating a patient as though he or she has sepsis and improvement is evident. Also, due to increased attention, many providers believe that sepsis is over-diagnosed in general and queried for by CDI and coding staff “too quickly.”

Here is a CDI example – say your patient has a WBC count of 17.5 and a heart rate of 115. Query for sepsis, right? Wrong! After further review you discover your patient has been on PO steroids, accounting for the elevated WBC count. He or she is also in afib with heart rates between 100 and 140, accounting for the elevated heart rate. 

Communication among the many consulting, rotating, and covering providers is paramount, as Doctor Day #1 may never speak to Doctor Day #3 about the patient’s presentation. The chart more and more is becoming a tool; documenting very clearly the patient’s baseline status on arrival, the patient’s objective clinical picture during the course of treatment, and ultimately the improvement and/or condition at discharge will allow for fluid clinical understanding and supportive data for confirming and ruling in/out certain diagnoses.

The takeaway from this? Physicians need to make sure they are correctly identifying and documenting sepsis early and starting to bundle treatment. CDI specialists need to know what a septic patient looks like. And coders need to know the guidelines and when it is appropriate to code sepsis.

Attempts at Making Sepsis a Core Measure are Not New

CMS previously has attempted to make sepsis a new core measure. However, after much feedback from physicians (particularly emergency department physicians) it decided to delay the implementation to 2016. The American College of Emergency Physicians’ (ACEP’s) biggest criticism of the new sepsis core measure bundle was that “not all elements of the composite 2012 NQF No. 0500 meet the criteria of being evidence-based. Specifically, we refer to the measurement of CVP and/or central oxygen saturation, both requiring placement of a central venous catheter.” The ACEP referenced several studies that found the following:

  • There were no differences in the primary mortality outcomes for septic patients who did or did not receive invasive monitoring.
  • The most important factor in reducing mortality in septic patients continues to be enactment of early antibiotics, aggressive fluid resuscitation, and source control without invasive monitoring of CVP and ScVO2.

ACEP’s final remarks on the CMS sepsis bundle is well-stated: “ACEP will continue to strenuously object to requiring steps that deliver limited benefit without clear evidence that creates the opportunity for unintended patient harm and impedes real quality improvement.”

The concept of “real quality improvement” is extremely important here, and it’s something physicians have been shouting from the rooftops for years. Yes, all physicians want to provide excellent care with good outcomes, and evidence-based bundles help them do this. But should hospitals and physicians be punished for not following bundles to a tee when they show no true quality improvement or positive outcomes?

The new severe sepsis core measure bundle has 53 measures. Lisa Swanson, quality improvement coordinator at Community Hospital in Grand Junction, Colo., shared the following: “at our hospital, we already have a sepsis bundle, but we are going to have to make some changes to it. For severe sepsis there are 53 measures, and it is all or nothing. So if we only meet 52 of those measures, you fail the measure completely.” 

Sepsis and ICD-10: New Coding Guidelines

Not only is sepsis set to become the new core measure for 2016, ICD-10 is supposed to be implemented on Oct. 1, 2015. Fortunately – and unfortunately – there are new ICD-10 coding guidelines for sepsis. In the current ICD-9 code set documentation, a patient’s record of “SIRS 2/2 to (infection), present on admission” is final-coded to one of the sepsis DRGs (872, 871, 870). However, in ICD-10 this same documentation will take us to a principal diagnosis of whatever the infection is. So documentation of “SIRS 2/2 to pneumonia, POA” will take us to the pneumonia DRG. This is a massive modification to the coding guidelines, and if not reviewed and queried for by coding and CDI staff, it could lead to patients inappropriately being coded to improper DRGs that do not reflect the high level of care they received for sepsis.

Another requirement for ICD-10 is ensuring that end-organ dysfunction is linked to severe sepsis. When a patient is experiencing severe sepsis the provider must document a relationship statement such as “severe sepsis with acute renal failure” so that we may code the severe sepsis. In ICD-10, if “severe sepsis” is in one note and “acute renal failure” is in another note, no assumption of a relationship can be made.

Simplified Guidance for Documentation of Sepsis in ICD-10

  • If your patient has sepsis, document it, not “SIRS 2/2 to ____.”
  • Document POA status.
  • When documenting severe sepsis, make a relationship statement between it and the end-organ dysfunction. “Severe sepsis with acute respiratory failure.”
  • If your patient is in septic shock, document it. “Hypotension” is not equivalent to shock.

Sepsis and Value-Based Purchasing

What does sepsis have to do with value-based purchasing (VBP)? Essentially, VBP will result in hospitals receiving incentive payments for providing high-quality care. Identifying sepsis early, treating it, and documenting it appropriately are all part of VBP. The only way CMS knows if your patient had sepsis, how they were treated for it, and if they lived or died is based on provider documentation. That’s it.

Sepsis could affect VBP in three of its four components: process of care and core measures, cost efficiency, and possibly outcomes and 30-day mortality rates. As mentioned above, sepsis will be a new core measure in 2016, meaning it could be one of the 12 chosen by CMS to be measured regarding VBP. In theory, it should cost less to care for a patient with “just” pneumonia than a patient who is septic; if sepsis is under-documented or not documented clearly enough, this could show a high cost of care for less sick patients in DRGs with low relative weights. As of 2015 the CMS outcome measures for VBP are 30-day mortality rates for acute MI, heart failure, and pneumonia. In the future sepsis easily could be added to this list. Plus, if those pneumonias that could be sepsis are not identified as such, they are going to fall into this bucket anyway.

Lastly, if sepsis is under-identified, a hospital’s severity scores and likely their observed versus expected mortality scoring will suffer. “Suffer” in this case means that when compared to your cohort hospitals, it may look like you provide poor care to not-very-sick patients (or at least non-septic patients).

With the inception of VBP it is more important than ever to get sepsis accurately documented. If you do not have excellent team members, consisting of quality, CDI, and coding, you may need to rethink your approach to tackling sepsis as a core measure in 2016.

About the Author

Rachel Mack is a Senior Healthcare Consultant for Panacea Healthcare Solutions where she performs clinical documentation and quality chart audits that focus on identifying missed opportunities to obtain an accurate and complete record for each patient.  Rachel has nursing experience in CVICU, ICU, and home health and has worked in Clinical Documentation Improvement as a CDI Specialist and CDI Educator.  She has written various articles and assisted in creating CDI training materials.  She was also a presenter at the 2015 ACDIS conference.

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