Use SOI/ROM scores to enhance CDI program effectiveness
Although MS-DRGs have stolen the spotlight since CMS implemented them in 2007, hospitals are increasingly using All Patient Refined DRGs (APR-DRG) to compile the most accurate assessment of patient severity of illness (SOI) and risk of mortality (ROM).
As with MS-DRGs, APR-DRGs are divided into Major Diagnostic Categories. However, APR-DRGs are adjusted to better reflect a patient’s true clinical picture, which makes them extremely valuable for data analysis, said Manchenton.
- 1: Minor
- 2: Moderate
- 3: Major
- 4: Extreme
- Uncomplicated diabetes (ICD-9-CM code 250.0x): SOI 1 (minor)
- Diabetes with renal manifestations (ICD-9-CM code 250.4x): SOI 2 (moderate)
- Diabetes with ketoacidosis (ICD-9-CM code 250.1x): SOI 3 (major)
- Diabetes with hyperosmolar coma (ICD-9-CM code 250.2x): SOI 4 (severe)
- Premature beats (427.60): ROM 1 (minor)
- Sinoatrial node dysfunction (427.81): ROM 2 (moderate)
- Paroxysmal ventricular tachycardia (427.1): ROM 3 (major)
- Ventricular fibrillation (427.41): ROM 4 (severe)
“Sometimes, the physician is so busy discussing the congestive heart failure and the shortness of breath associated with it that he or she is not giving us the full diagnosis related to the respiratory component,” said Manchenton. “What is the CHF doing to the lungs? If we had gotten that specified—if it was clinically appropriate to be acute respiratory failure—we would be in the highest SOI and ROM subclasses.”
- Initiate process improvement. Each month, a mortality committee meets to discuss deaths and seeks to understand the balance between quality issues and documentation issues. The physician-led committee includes those from the quality assessment department as well as physicians and representatives from various specialties and disciplines. In particular, the committee helped identify certain physicians who now review all deaths that occur due to acute myocardial infarction, pneumonia, and CHF before final coding to ensure that the code assignment reflects the patient’s total clinical picture.
- Focus CDI reviews. CDI staff use expected mortality rates to focus chart reviews on patients with an ROM or SOI score of less than 4 who expire. Staff review records after coding but before the bill is dropped to assess for any opportunities to better reflect the patient’s SOI and ROM in the documentation.
- Provide physician education. CDI staff use actual ROM scores and examples to educate physicians about how better documentation can affect profiling data.
- Capture all secondary diagnoses that meet reporting requirements—especially those that aren’t related to the PDX
- Improve specificity of secondary diagnoses
- Collaborate with the core measures team and quality department
- Ensure accurate assignment of the POA indicator
The record is what truly tells the story, and it should include all details about the patient’s complexity. This is helpful not only today, but also in preparing for ICD-10, said Manchenton.
“When your record is complete, accurate, and compliant, you get an accurate profile and an appropriate reimbursement,” she said. “When you start focusing on profiling and getting better specificity, you’re already getting a jumpstart on your ICD-10 preparation.”
Editor's Note: This article first published on JustCoding.com.