Q&A: Mortality reviews
Q: What is the pathway for mortality cases at your organization? We review the mortality cases that have a risk of mortality (ROM) and severity of illness score of 4 or below, and to improve the observed to expected ratio (O:E). The workflow, however, is inefficient, and the CDI team complains about how time consuming it is to review mortality charts, respond to the emails regarding the mortality cases, and reconcile the code set for the mortality cases. Our current process is that we have one CDI specialist who receives all the mortality cases, fills a spreadsheet, and then directs the mortality case to the CDI specialist on the record for further review. Then the communication between the CDI specialist and coder starts.
Response #1: We have centralized our mortality reviews with our CDI quality team or the CDI manager. Currently, we are doing reviews on cases that are not yet at SOI/ROM scores of 4/4. We also recognize that this is a very minimalistic approach to mortality reviews. Until we have some better tools and also have additional resources to address a more robust review, we will be doing the same. If we adopt a more robust review in the future, we plan to keep this task with the CDI quality team. The person doing the review will evaluate the case for query opportunities or coding review (if there is a question about missed codes). They will follow up with the query and/or coding review and then submit the case for final coding and billing.
Response #2: We have a team composed of a second level reviewer CDI specialist and senior coder that reviews all patients who expire (as well as second level reviews of all patient safety indicators [PSI]/hospital-acquired conditions [HAC]) in our system. The volume averages 40 to 50 mortalities and 10-20 PSI/HACs per week. The CDI specialist will send the mortality/PSI/HAC queries on all accounts, even those with previous CDI reviews, then the CDI specialist and coder will work together to get the code summary correct on those accounts. The reviewers are supposed to provide feedback/education during a combined CD/coding huddle regarding their findings and opportunities. The volume of work these two perform has grown too much to provide much more than a raw abstract of what they are finding, so we are exploring our second level reviewers returning some accounts to the coder/CDI team to work on.
Response #3: Our mortality reviews are identified in two ways. When the final coding is done, coding will notify the CDI specialist if the patient expired and their SOI/ROM is less than 3/3. Also, the Lead CDI specialists have a work queue which includes patients who expired or were discharged to hospice. When identified, the lead will review the case.
Response #4: At our organization, we strive to optimize SOI/ROM on every case we review. We additionally will look for Vizient’s most frequent and heaviest weighted predictors of mortality, and have a few diagnoses that are focused reviews, in which we will review against the specific Vizient model for that DRG. Retrospectively, all expired cases are held for review by the coding validation team, who again are focused on optimizing SOI/ROM and Vizient mortality predictors.
Response #5: We have a morality nurse who is a full FTE working on all morality. It is very time-consuming. She takes the case over after the patient is deceased and then uses the Vizient Model group and queries appropriately. It does not go back to the CDI specialist who opened the case. She will also do a full review of a case that has not been seen at all by the CDI team.
The 4/4 SOI/ROM score does not always equal risk adjusted mortality, so we do not consider that as a variable.
Response #6: Our mortality review process is performed by our retrospective CDI team. Understanding the mortality reviews take longer than normal reviews, the extra time is factored into the productivity model. We review with the same historical goal of SOI/ROM 4/4 but also use the Premier Risk Calculator to get to the highest risk percentage. That calculator helps us to identify diagnoses that impact the risk that may not have been identified in the normal SOI/ROM review. It also adds time to the review process and thus the need to give the team more time on those reviews.
Editor’s note: This question was answered by members of the ACDIS CDI Leadership Council and originally appeared in the CDI Leadership Insider, the monthly newsletter for members of the Leadership Council. For the purposes of this article, all Council member answers have been deidentified.