Thursday, May 17, 2018

"I'm Dr. CC. Get Your Medicine From Me."

By way of introduction, this post refers to specific terms in Clinical Documentation Improvement (CDI).  Hospital payment within Medicare is based on a scheme called MS-DRG's, or Medicare Services Diagnosis-Related Groups.  Within each group, the severity of a patient''s illness and needs for care can be further specified by documentation of Comorbid and Complicating Conditions (CC's) and Major Comorbid and Complicating Conditions (MCC's).  This post addresses CC's I wish we could use.  A couple of them are legitimate clinical issues...and the others?  I'll let you decide.  Meanwhile, Spotify's playing Clarence Carter...

A few weeks ago, I was giving a presentation to a group of surgeons.  I was talking with them about CDI, which as you might imagine is as near and dear to the heart of the surgeon as mindfulness is to Daffy Duck.  My comments engendered a surprising amount of discussion, the upshot of which was that maybe all patients should just be admitted to the hospitalists with surgical consults, as the hospitalists write more stuff anyway.  (True story.  And an idea not totally without merit.)

One surgeon asked an interesting question when I was describing what “makes” a CC.  “What about being homeless?  These people can’t keep their wounds clean, can’t get to follow-up care, can’t get their medicines.  And what about non-compliance?  Doesn’t that count for something?”

The short answer, which you know as a CDI geek, is that it doesn't.  These social circumstances, while subject to coding when documented, count for nothing within the DRG scheme.  The unmistakable message is that either they’re entirely discounted and negligible, they’re so ubiquitous that everyone’s care is complicated by it and therefore no one’s is, or they’re common enough that to give credit for them will costs real money.  But as a clinician, I can’t tell you how many patients have prolonged their own courses through their own non-compliance, or are difficult to discharge safely because they literally have nowhere to go.  Working with patients, there’s no question that these circumstances prompt additional evaluations, require more extensive treatment palms, prolong length of stay, and promote readmissions.  But while codes exist within ICD-10-CM for these circumstances, they count for nothing within the MS-DRG scheme.

I also realized I didn’t know how something becomes a CC or an MCC.  I figured somehow it worked through the Cooperating Parties (AHA, AHIMA, CDC, CMS), but I had no idea how.  Is there a nominating committee, and do the wines each year get revealed at an awards show?  (The nominees for Best CC Related to a Catheter are…can I have the envelope, please?)  Maybe it’s an illuminati kind of things, with a select few sacrificing a goat while intoning the definition of a Secondary Diagnosis?

Because I have no life (at least that week…the Dental Empress was in Tampa with her high school friends falling out of a sea kayak while the College Student sat in his room, emerging only to permit The Father to do Chauffeur Duty), I decided to find out.  An inquiry to Coding Clinic has been submitted and I eagerly await the reply.  But until I do, why not mull over some of those conditions we see that might be eligible to join these hallowed ranks.  So here’s my list of proposed CC’s, some real, some…well, real, but less likely to stick.

Non-compliance:  There is absolutely no question that medical non-compliance impacts patient care.  In some cases, non-compliance may actually be the principal driver of admission, if a condition that was otherwise well-controlled exacerbates because a patient was non-compliant with treatment or follow-up plans.  Non-compliance while in the hospital can also lead to the need for further interventions and care.  (An internship memory is of a 450 pound man who kept going into CHF no matter how many diuretics we threw at him the day before.  Turns out he was getting salt-loaded in the hospital with midnight family ruins to Taco Bell, and when he was at home he had no air conditioner so he kept drinking cold sodas to stay cool.  Discharge plan was no fast food and the hospital chipped in a hundred for a wall unit.  Kept him out all summer.  It was a simpler time.)

Granted, there are patients for whom non-compliance is not of their choosing.  People may simply not be able to afford their medications, have transport issues to and from appointments, or be able to take time off work for needed follow-up.  Perhaps patient education hasn’t been up to snuff, or educational deficits prevent honest understanding of the Plan of care.  Some prefer the newer term “non-adherence” to describe the behaviors of this group, because they can’t adhere to treatment through no fault of their own.  That makes some sense to me.

However, while it is absolutely not politically correct to say so and flies in the face of most of our extreme liberal concepts, it seems inescapable that often one chooses their fate.  I got close to fisticuffs in a small group discussion about the social determinants of heath. These are things like race, income, education, geography, etc, all of which can absolutely impact upon health and health care.  No argument there.  But when I noted that in my ER life, there were a subset of folks who every Friday, unbidden by cultural concerns or peer pressure, feel compelled to go to the bar and get their head whacked with a pool cue, that was considered anathema to the modus of the day.  And yet people make the same bad choices over and over. How many times have I been married again?

Homelessness:  If we spoke before about the social determinants of health, homelessness has to be near the top of the list.  Homelessness complicates care for all the reasons you might expect…inability to get medications, inability to attend follow-up…as well as preventing basic hygiene, all of which can result in increased needs during a hospital stay.  Homelessness can also delay discharge while Case Management seeks out someplace for the patient to go.  Clearly CC material.

Patient with Relative in Health Care:  If the worst words an ER doc can hear are “Remember that patient you saw last night,” the third worst are “My aunt is a nurse.”  (I’ll save the second worst for another time.) Nurses are good people, and they want to be helpful.  So when a relative calls they rattle off all the possible diagnoses, give them a list of all the tests that could possibly be performed, and then send them to the ER with all this in hand.

Once you see the patient and offer you thoughts based on years of training and experience, they hand you the cellphone and make you talk to the relative “who’s a nurse.”  (If you’re lucky, you get to stand in the room for fifteen minutes while they call another relative to look up the number.)  You have to talk to them before you order labs and xrays, discuss the results with them, and clear any plan, because the relative in the ER insists that you do.  Meanwhile, the “nurse” has usually called the patient’s own physician who’s been jolted from his sleep and demands to know exactly how and why you’re killing the patient.  If the case gets to the floor, repeat twice daily and toss in a few calls to the Respiratory Supervisor and Case Management to boot.  Of course, the patient will stay just a few days longer because the nurse has to approve of the discharge plan.  One forward-thinking hospital I know of uses measures of nursing intensity that account for the “difficult family.”  Ahead of the curve.

(Did I mention that most of the time the relative who’s a “nurse” is an aunt or cousin who’s actually a CNA in a nursing home?)

Interestingly, patients whose relatives are doctors are equally insistent on passing the phone to you, but the doctors themselves are usually much easier to deal with as they still don’t want to wake up at night, no matter who’s calling.  (As my father says, “Family practice doesn’t mean your family.”)  Attorney relatives are even more of a breeze, because somewhere in their cold little prune hearts they probably realize that if their second cousin is calling from the ED from 3 AM and already wants to sue, there’s probably some craziness there. 

Being form New York:  This similar to Nurse as a Relative in workload impact, but seems to be limited to Snowbirds and Tourists whose primary domicile in within Manhattan.  To put it delicately, New Yorkers are supremely confident that everyone else is a moron.  This includes physicians, which is why anytime a patient is from New York City I’m supposed to check with their own doctor, who is on staff at Columbia University or Mt. Sinai Medical Center or the like, before I do anything.  (This is one time that I thought having a Jewish last name might help, but my accent gives away that I’m not one of them.)

When this happens, there is a part of me that wants to tell them that the way you get on staff at an academic medical center is to do a residency there and be too scared to leave.  That the title “Clinical Associate Professor” means nothing but you’re in private practice and you let some medical students tag along.  That the problem with the Big East Medical Centers is, in the words of a Johns Hopkins Residency-Trained Specialist, ”They don’t understand that you can get good neurosurgery in East Pigsty, Rhode Island.”  But it’s not worth the time it takes to orient these Yankees back to reality.  So I dutifully call the doctors as requested, whom I think are trying to be as nice as a New York doctor can be while dealing with their inferiors.  The one redeeming feature of these calls is that doctors from Brooklyn, Queens, and The Bronx tend to swear a lot, so it’s fun to put their direct quotes in the medical record and see if there’s a code for the diagnosis of “low pain threshold wuss.”  (That’s the polite version.)

Of course, it’s not all diagnoses.  There are some procedures that should be CC’s as well.

Intubation for airway protection:  Patients are not always intubated for respiratory failure.  On many occasions, they’re intubated for airway protection.  The intoxicated patient or the patient with seizure or stroke may have an adequate respiratory drive, but altered levels of consciousness, diminished gag reflexes, or difficulties with swallowing raise the risk of aspiration and mandate that airway compromise be prevented.   While the patient who is intubated purely for airway protection may be an inpatient for the same amount of time as one that is not intubated…your alcohol burns off at a similar rate whether you’re “smoking plastic” or not…there is no question that the level of nursing care and monitoring required of an intubated patient exceeds that of a non-intubated peer.  This one should be a no-brainer.

Use of an Electronic Medical Record or Patient Satisfaction Surveys:  Find me the doctor, nurse, or other professional involved in patient care who says the EMR improves their workflow, speeds their day, enhances patient care, and simply makes their life better.  While you’re at it, send me the docs who think that Patient Satisfaction Surveys do the same.  Begin now.

I’m waiting.

Still waiting.

What if there were free cookies in it?


Enough said. 

Administration of Turkey Sandwich and Sprite:  This common clinical procedure contributes to measures of resource intensity through the need for staff to acquire the sandwich, apply required condiments, put ice in a cup, locate a straw, and cut off the crusts for those of tender gums.  Multiple applications are often required, and may be accompanied by the need for puddings and fruit cups.  Paradoxically, provision of such comestibles may actually enhance measures of Utilization Management, especially when used to drive early discharge in the Observation Setting.
Hey, it’s Grammar Guy here.  I can live with the political correctness of “Medical Non-Adherence.”  However, I can’t reconcile with the term “Psychogenic Non-Epileptogenic Seizure.”   This is what we would usually call a pseudoseizure, but given a new label because psuedoseizure conveys the impression that patient is faking and maybe the poor dears just can’t help it.  It’s kind of like saying that when I was in my twenties and dating several girls at once I was having “Psychogenic Non-Intentional Cheating Behavior” instead of being a Hormonal Lying Cheating Dog.   The only saving grace about this term is after I explained it to a paramedic, he would take great delight in calling in on the radio about PNES seizures.  And yes, it’s pronounced exactly like you think. 

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