Q&A: CDI expansion into OB-GYN

While outpatient CDI has become the hot topic for the industry as a whole, other areas present ready opportunities for CDI intervention. OB-GYN is one such area. Abby Steelhammer, MBA, MHA, RN, director of clinical documentation excellence at Novant Health, Michelle Walters, MSN, RNC-OB, and Sandra Surratt, RNC-OB, BSN, women’s services CDI specialists with Novant Health, joined ACDIS Director Brian Murphy on October 11 to discuss their OB-GYN program on ACDIS Radio.

In response to the show, the speakers responded to some listener questions to share with the ACDIS and CDI community.

Q: How did you educate providers on documenting severity of illness (SOI)/risk of mortality (ROM) in a codeable way to reduce the early elective delivery metrics (what specific wording did you teach the providers)?

A: We reference guidelines per the Joint Commission’s website at www.jointcommission.org/perinatal_care/, “Conditions possibly justifying elective delivery prior to 39 weeks’ gestation.” We encourage complete and accurate documentation of any and all appropriate diagnoses that may illustrate the cause and effect/rationale for an early elective delivery when it is justifiably under the 39-week specification, such as “spontaneous rupture of membranes (SROM)” further specified as “premature rupture of membranes (PROM) or preterm premature rupture of membranes (PPROM).” Other examples would be to clarify “gallbladder disease” to “acute cholecystitis,” as clinically applicable.

Q: When you mentioned preeclampsia with acute hypertensive disorder causing impact, what specifically do you mean by that?

A: With presenting preeclampsia, a patient may have an acute hypertensive episode and we use an order set to manage these acute episodes entitled “hypertensive emergency.” We educate providers to document diagnoses that accurately reflect resource consumption; hypertensive emergency (CC), and hypertensive crisis (CC) impact DRG, SOI, and ROM, along with chronic hypertension, which changes the DRG for a vaginal delivery.

Q: Do you have any suggestions for the antepartum patients that have long lengths of stays, but the DRG allows only two days?

A: These are definitely challenging. We emphasize documenting all secondary diagnoses. Physicians tend to just focus on the pregnancy and omit documenting chronic conditions affecting the pregnancy, and thus affecting the delivery. If they’re treating conditions, continuing, changing, or adjusting medications, and/or requesting consults, then these diagnoses should be documented.

Q: Can you go into a little more detail about required documentation related to the ruptured membranes?

A: ICD-9 defined three codes for rupture of membranes, versus 25 codes in ICD-10, which allow for greater specificity around trimester and onset of labor. We lost the ability, however, to code for SROM, and this is the most common way providers document rupture of membranes (ROM). We encourage documentation of “PROM” or “PPROM” for patients presenting with “SROM.”

Editor’s note: To listen to the complete ACDIS Radio episode, click here. To download a 2017 ACDIS Conference presentation on the topic of CDI in OB-GYN, click here.