Chapter 1 Key Terms Flashcards
Principle Diagnosis
The condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.
Other (Additional) Diagnoses
All conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay. This is interpreted to be any condition that affects patient care in terms of requiring clinical evaluation; therapeutic treatment; diagnostic procedures ; Extended length of hospital stay; or increased nursing care and or monitoring.
Procedures
All significant procedures are to be reported. Significant procedures are those that are surgical in nature; carry a procedural risk; carry an anesthetic risk; or require specialized training.
Complication/comorbidity(cc)
A condition that when present leads to substantially increased hospital resource use such as intensive monitoring, extensive and technically complex services, and extensive care requiring and greater number of caregivers.
Major complication/comorbidity (mcc)
Diagnosis codes that reflect the highest level of severity (see also CC above)
Risk of mortality
Medical classification to estimate the likelihood of a hospital death for a patient. The ROM classes are minor, moderate, major and extreme. The ROM class is used for the evaluation of patient mortality. Is also used for profiling.
Diagnostic-Related Group
Classification system of diagnoses in which patient demonstrates similar resource consumption and length of stay. (takes into account the presence of cc and/or mcc’s)
All Payer Refined DRG (APR-DRG)
A severity based classification system. (Takes into account all secondary diagnoses, along with other factors, to calculate a SOI & ROM score.)
Present on Admission (POA)
All claims involving inpatient admissions to general acute care hospitals or other facilities that are subject to a law or regulation mandating collection a present on admission information. We are required to add a present on admission indicator to all diagnoses. Reporting options are Y yes, N No, U, unknown, W, clinically undetermined Blank field exempt from POA reporting (Certain conditions when labeled as “not POA” are then considered to be Hospital Acquired conditions or HAC’s for which reimbursement is not provided.)
Diagnosis
All diagnoses that affect the current hospital stay are to be reported.
What is clinical documentation and why does it matter?
Clinical documentation improvement or CDI is an educational program utilizing documentation specialists to translate the medical record concurrently in collaboration with providers.
The review process consists of preventing and reconciling inconsistent, incomplete and conflicting provider documentation prior to the final assignment of ICD – nine codes and the final DRG for billing and data collection.
Positive impact of clinical documentation improvement
Positive, strong, concise and complete documentation reflecting the delivery of high-quality healthcare services, as well as painting an accurate picture of the patient’s illness, supporting the coding of medical records to their greatest level of specificity.
Collaboration across organizations, including HI am, information technology, infection control, revenue cycle, etc.
Accurate quality reporting
Timely and correct reimbursement
Ability to meet revenue cycle goals, such as submission of clean claims and reduction of days in A/R
Best practice in CDI
Complete and accurate documentation supports coding which is the basis of correct revenue and reimbursement; otherwise, a hospital could be losing revenue
Complete and accurate documentation is necessary for complying with quality measures
Quality information supports care management and the use of the appropriate protocols.
Negative impact of unclear clinical documentation
Incomplete information for coaches to coach from.
Inaccurately low case mix index
Incorrect reimbursement
Faulty quality scores based on coded data Consumer reports published annually Healthgrades upgrades every six months Joint commission quarterly publicized Leap frog upgraded every six months
Patient care is impacted when medical information is unclear to the following/next provider
Additional cost incurred due to potential repeat the test, exams and treatments when documentation is missing
Multi-health care organizations feel the impact of poor provider documentation as they share data within a health information exchange or accountable care organizations
How healthcare organizations are affected by clinical documentation
Five factors related to severity of illness
Hospital cost. Hospital length of stay. Mortality/remission rate. Patient safety indicators. Hospital acquired conditions
