Learning Objectives. Ambulatory CDI: The New Horizon

Transcription

1 1 Ambulatory CDI: The New Horizon Mary Alvarado, MD, Ambulatory CDI Physician Lead Jennifer Conroy, RN, BSN, CDI Manager Andrea Benzing, CPC, Ambulatory CDS Gundersen Health System La Crosse, WI Learning Objectives At the completion of this educational activity, the learner will be able to: Better understand the challenges specific to ambulatory CDI and identify the scope for a program Understand personnel structure options Establish the training and onboarding of CDI specialists as well as providers and identify strategies to engage medical providers Implement a daily workflow Better understand the impact of the EMR on CDI and the resources to navigate it and track progress 2 Gundersen Health System A comprehensive healthcare network of wholly owned services, regional partners Physician led, not for profit Regional referral center Located throughout Western Wisconsin, NE Iowa, and SE Minnesota, caring for patients in 19 counties First health system to achieve energy independence in

2 4 Gundersen Health System Gundersen s CDI Goals Accurately represent Gundersen Health System in administrative databases Capture the true severity of illness Demonstrate medical necessity and patient complexity Document quality of care given To improve physician quality score To optimize reimbursement Support value based purchasing 5 Inpatient to Ambulatory CDI Inpatient clinical documentation improvement program launched in 2010 Late 2011 consultant review High % of nonspecific diagnoses in ambulatory setting Early 2014: Concerns by providers: Documentation integrity ICD 10 Maximizing documentation for reimbursement 6 2

3 7 Inpatient to Ambulatory 2014: Consultant group denials analysis medical necessity Emergence of CDI programs in the ambulatory setting Inpatient CDI metrics from 2014 were outstanding Gundersen s Inpatient CDI 2014 Outcomes 7,031 CDI scope charts reviewed 91% review rate 2,188 clarifications sent 30% of cases with a clarification 98% provider response rate 89% positive response rate 8 Importance of Ambulatory CDI? The pendulum in U.S. healthcare is swinging from a QUANTITY driven system Fee for service To a QUALITY driven system Value based purchasing Bundled payments Incentives Pay for performance Penalties for avoidable complications 9 3

4 10 Getting Started Initial Ambulatory Development Andrea Benzing identified to help lead initiative Dr. Alvarado was identified to be physician lead Focus to be CMS Hierarchical Condition Categories (CMS HCC), as well as accuracy of the EMR problem list 11 Why Focus on HCCs at GHS? Spring 2014: Initial HCC education and electronic medical record (EMR) functionality training Classroom education done by EMR physician educators Potential of millions of $$ to Gundersen Health Plan (GHP) HCC Best Practice Alert (BPA) introduced 12 4

5 13 Why Focus on CMS HCCs at GHS? Spring 2015: Reevaluated HCC capture Workflow processes HCC audit report from GHP Functionality and tracking of HCC BPA BPA concerns What Were Some Alternative Options? Maximizing evaluation and management Denial management and prevention Outpatient procedures Alternative CMS HCC focused methods Key diagnoses 14 CMS HCCs Risk adjustment model for Medicare Advantage plans since 2004 Based on: Patient characteristics (age, gender) Medicaid status Living status (institution versus community) ICD 10 CM codes Used to prospectively predict costs for the next calendar year 15 5

6 16 HCCs CMS HCC categories 9,000 diagnosis codes map to 79 HCC categories Categories are weighted and affect the risk adjustment factor (RAF) Rx HCC predicts the amount of medications/therapies a patient will require in the following year Rx HCCs and HCCs are to the outpatient chart what CCs/MCCs are to the inpatient chart HCCs Change in thinking for providers HCCs are based on medical risk Fee for service is based on what providers do (procedures, visits, etc.) More practical education was imperative, particularly for primary care providers Within our EMR, both are now identified with an asterisk 17 CMS HCC Requirements Physician/PA/NP must: See patient at least once per calendar year Face to face visit Document all HCCs Non provider visits (lab, ambulance) do NOT qualify Code conditions to the highest level of specificity 18 6

7 19 GHS Documentation Criteria Documentation of diagnoses should show one aspect of MEAT: Monitoring, Evaluating, Assessing/addressing, OR Treating Problem based charting Avoid simple listing of diagnoses MEAT Examples CHF (acute/chronic, systolic/diastolic): Symptoms well controlled with Lasix and ACE inhibitor. Will continue current medications. Major depression: Patient continues with feelings of hopelessness and anhedonia despite current regimen of Zoloft 50 mg daily. Will increase to 100 mg daily and monitor. DM, controlled: Stable on medications. No complications noted. order labs. 20 CMS HCC Capture Stress specificity tells the accurate story of the patient Stress quality of care not simply reimbursement Goal for providers Take excellent care of patients Goal for CDI Accurately document how sick patients are so that we can continue to take excellent care of patients 21 7

8 22 How Will It Work? Key stakeholders met in August 2015 to develop plan Executive leadership Director of mid revenue cycle Gundersen Health Plan leadership Physician leadership CDI manager and CDI specialist Process identified Staffing discussed Pilot planned The Process Prospective/concurrent vs. retrospective review Focus on annual wellness and Welcome to Medicare visits for senior preferred patients Initial review to scrub the chart 2 weeks before date of service (DOS) Careful review of the problem list Messages will be sent through inbasket in EMR 23 Pilot Identified 4 engaged providers to start with 2 good documenters 2 providers with potential for improved documentation Initial education HCC review EMR efficiencies review with mentoring Importance of accuracy of the problem list Process review Shared clarification templates Follow up meetings for feedback 24 8

9 25 Pilot Added more providers as able introduction Face to face meetings Individual provider meetings Department meetings Regional and main campus Education geared to their location and clinic flow Staffing Coding background felt to be essential Comfortable interacting with providers RNs not felt to be essential in the initial workflow Initial staffing 2 former revenue integrity advisors 1 coder with internal medicine coding experience Expansion concerns Is clinical experience necessary? Difficulty finding qualified applicants Unknown new department 26 Staffing Expansion options Model on inpatient RN onboarding Post as a RN role Work closely with human resources and recruitment Current staffing 2 staff with coding background 3RNs 27 9

10 28 Training Nurses Overview of risk adjustment Documentation requirements Inpatient vs. outpatient Coding guidelines/icd 10 CM Risk adjustment boot camp Coders Overview of risk adjustment Documentation requirements Inpatient vs. outpatient Clinical concepts Disease processes Getting Down to Business 29 Workflow Pre visit chart scrubbing Previously billed diagnoses Documentation of professional services Pre visit query Discrepancies or unspecified conditions on the problem list Status conditions 30 10

11 31 Pre Visit Query Example Dear Dr. ***, *** has an annual wellness visit scheduled with you on ***. According to the medical record, the patient has a documented BMI *** on date of service ***. If you feel it is pertinent to evaluate this condition at the upcoming visit, please include the diagnosis and treatment plan in the visit note and update the problem list. Obesity guidelines Obesity = BMI > 30 Severe obesity = BMI > 40 Morbid obesity = BMI > 40 Please use REPLY to indicate you have reviewed the diagnosis (diagnoses) Pre Visit Query Example Dear Dr. ***, The following discrepancy in *** chart was found in the problem list: (Describe the discrepancy) Please update the problem list according to the conditions that are pertinent to the patient. Please use REPLY to indicate you have reviewed the problem list and indicate whether or not any updates have been made. 32 Workflow Post visit review Within one business day CMS HCC and Rx HCC documented MEAT criteria Specificity Post visit query Missed CMS HCC or Rx HCC No MEAT Problem list updates 33 11

12 34 Post Visit Query Example Dear Dr. ***, *** was seen on ***. The following diagnosis was documented in the visit note (DOS: ***) but does not appear on the patient s problem list: (Describe the diagnosis) If you feel this condition remains pertinent to the patient, please update the problem list. Please use REPLY to indicate whether or not any updates have been made. Post Visit Query Example Dear Dr. ***, According to the progress notes on ***, the following diagnosis has been documented for ***. (Describe the diagnosis) I am having difficulty finding documentation that supports the MEAT (monitor, evaluate, assess, or treat) criteria for this diagnosis. Please add supporting information if this condition was pertinent and addressed at this visit. Monitor = signs, symptoms, status Evaluate = test results, medication effectiveness Assess = order tests, discuss, counseling Treat = medications, therapies Please use REPLY to indicate whether or not any updates have been made. 35 No MEAT and Missed Rx HCC 36 12

13 37 Query The following conditions were selected as a visit diagnosis and also listed under the assessment. I'm having difficulty finding documentation on how these conditions were monitored, evaluated, assessed, or treated. Mixed hyperlipidemia Postoperative hypothyroidism Hypertension The following condition is currently listed on the problem list but has not been addressed or reported in a face to face visit this calendar year. Major depressive disorder, recurrent, in full remission If these conditions were pertinent and also addressed at this visit, please update the documentation with how they were monitored, evaluated, assessed, or treated. Post Query 38 Final Review Work queues Appropriate diagnosis application Supporting documentation Additional conditions not captured 39 13

14 40 Initial Tracking Application Spreadsheet Patient MRN/name DOS Provider HCC on problem list HCC captured in current calendar year HCC captured at AWV with supporting MEAT Type of query sent and response to query Manual reporting process Current Tracking Application Internal application on intranet Patient MRN/name DOS Provider HCC on problem list HCC captured in current calendar year HCC captured at AWV with supporting MEAT Type of query sent and response to query Electronic reporting process

15 43 Detail Screen Detail Screen 44 Dropdown Options 45 15

16 46 Query Screen Query Screen 47 Key Factors Overview 48 16

17 49 Key Factors Overview Leadership support Sponsored by medical staff executive committee Support from director of medical education Physician leads and provider champions CDI staff and coding specialists aligned with common director Key Factors Overview Organizationwide introduction to CDI in conjunction with ICD 10 education Focused ambulatory CDI pilot with feedback Clarification process through EMR Onboarding process for new providers and residents 50 Key Factors Overview Ongoing education and recognition Ongoing work to customize our EMR to reduce the documentation burden Strong focus on relationships, trust, and mutual respect 51 17

18 52 Our Ambulatory Provider Support Lead ambulatory physician 0.1 position (4 hrs/week) Primary care physician champion Outpatient department liaisons Inpatient providers support as needed: Lead inpatient physician 0.2 position (8 hrs/week) General surgery physician champion Additional hospitalist physician Ortho nurse practitioner champion Physician Responsibilities Serve as a resource for clinical questions Collaborate with colleagues to establish clinical definitions Facilitate discussions in peer groups and help mediate opposing views Provide medical provider orientation and education 53 Alignment of CDI/Coding Leadership Director of Mid Revenue Cycle and CDI Manager CDI Manager Coding Inpatient RN CDS Inpatient RN CDS Inpatient RN CDS Inpatient RN CDS Inpatient RN CDS Ambulatory CDS Ambulatory CDS Ambulatory RN CDS Ambulatory RN CDS Ambulatory RN CDS Hospital Billing and TEC/UC Coding Supervisor Department Coding Supervisor Hospital Professional Fees, Same Day Surgery, Department and Hospital Coding Supervisor Department Coding Supervisor Inpatient RN CDS Inpatient RN CDS Inpatient Facility, Outpatient Surgery, Observation and Facility TEC, Outpatient Departments Coding Supervisor 54 18

19 55 Organizationwide CDI/ICD 10 Education West Union, Iowa Gundersen West Union Clinic Provider Feedback Face to face feedback sessions with initial pilot providers Determined preference for mode of feedback Identified opportunities for improvements of EMR/reduction in documentation burden Majority of feedback done via EMR, occasional faceto face still needed 56 Clarification/Query Process CDI clarifications sent through Epic in basket Ambulatory CDI folder Standard templates used Response required Follow up process 57 19

20 58 New Provider/Resident Onboarding New medical providers are oriented within 30 days Orientation to medical providers given by CDI physician, RN manager, and a CDS Resident orientation General medicine Transitional medicine Family medicine General surgery Podiatry Provider Education Definitions CMS HCC and Rx HCC MEAT Examples of HCC capture Fee for service vs. pay for performance Importance of accuracy of problem list Optimal vs. suboptimal documentation Tailor education to provider specialty EMR/documentation tips Provide resources 59 The Good, the Bad, the Ugly 60 20

21 61 Room for Improvement Assessment: Assessment & Plan 1. Routine history and physical examination of adult 2. Need for vaccination against Streptococcus PNEUMO-CONJUGATE 13 VACCINE pneumoniae 3. Screening for ischemic heart disease (IHD) EKG 12-LEAD 4. Postmenopausal estrogen deficiency XR BONE DENSITOMETRY 2 VIEWS 5. Essential hypertension 6. Hypercholesterolemia 7. Postoperative hypothyroidism 8. Prediabetes Room for Improvement Assessment 1. Annual physical exam 2. Type 2 diabetes mellitus without complication 3. Need for prophylactic vaccination and inoculation against influenza 4. Actinic keratosis Plan 1. Labs/radiology ordered: Reviewed 2. Medications: No change 3. Immunizations: Flu shot 4. Preventive care: UTD 5. Return visit: 6 months 6. Other: None 62 Good Documentation Assessment & Plan: 1. Elevated cholesterol. She is encouraged to continue to be aware of the low-fat, low-cholesterol diet and exercise as she is able. 2. Essential hypertension. She will continue on her current medication regimen. I encouraged her to try and get this checked in the community. We did review her recent laboratory studies. 3. Acquired hypothyroidism. TSH returned mildly elevated. At this time, as opposed to adjusting the dose of medication, we will recheck a TSH when she returns in 8 weeks for her INR about that time. 4. Paroxysmal atrial fibrillation. She denies any palpitations, not having any change in her exercise tolerance. Symptoms are well-controlled. She will continue on the Coumadin anticoagulation

22 64 Good Documentation Diabetes mellitus with complication* (*) Microalbuminuric diabetic nephropathy* (*) Chronic atrial fibrillation* (*) Dyslipidemia Essential hypertension Uncontrolled based on HgbA1c level. I stressed the importance of regular exercise and a much more strict and consistent carbohydrate-controlled diet. Glimepiride increased to 4 mg daily. RTC in 3 months. Albuminuria controlled. Continue current ACEinhibitor and monitor Cr and RUMA annually. Stable. Ventricular rate well controlled. No TIA or CVA symptoms. No bleeding complications related to warfarin such as epistaxis, bleeding gums, hematochezia, melena, hematuria, or spontaneous bruising. Continue warfarin. FLPA is horrible due to medication noncompliance. Recheck in 3 months. BP is above goal, but med compliance very questionable. Routine monitoring lab results acceptable. Continue current medication. Encouraged to monitor BP regularly as an outpatient. CDI Resource Pocket Guide 65 Ambulatory CDI Resource Desk Guide 66 22

23 67 CDI Website Ongoing Education Recognizing successes Real chart examples Documentation tips Feedback from providers Graduating providers 68 Results of HCC Capture Before Query Diagnosis Unspecified atrial fibrillation CMS HCC Risk Adjustment 0 Factor (RAF) Rx HCC Risk Adjustment 0 Factor (RAF) After Query Diagnosis Unspecified atrial fibrillation CMS HCC Risk Adjustment Factor (RAF) Rx HCC Risk Adjustment Factor (RAF) Query sent for unspecified atrial fibrillation no MEAT criteria Query sent for moderate protein calorie malnutrition on problem list A. fib documentation updated: Metoprolol 12.5 mg for rate control, refilled Malnutrition was not discussed: Missed CMS RAF:

24 70 Results of HCC Capture Before Query Diagnosis Primary hyperparathyroidism CMS HCC Risk 0 Adjustment Factor (RAF) Rx HCC Risk Adjustment 0 Factor (RAF) After Query Diagnosis Primary hyperparathyroidism CMS HCC Risk Adjustment Factor (RAF) Rx HCC Risk Adjustment Factor (RAF) Query sent for primary hyperparathyroidism HCC not documented Documentation updated: Primary hyperparathyroidism, followed in endocrinology and has appointment in December. Continue excellent health practices. Provider Recognition s Electronic high fives Internal reward system sent with message to person and their manager Receive a pin Staff meetings graduating providers to audit review 71 Relationships/Trust Provide face to face education initial and ongoing Main/regional Primary/specialty clinics Tailor support to their specific needs Assure them adequate documentation helps reflect the quality of care they are providing, not simply improve reimbursement Listen to feedback 72 24

25 73 On to a New Horizon Success! Less queries being sent (47% to 31%) Improved responses (up to 86%) Improved agreement to queries (40% to 62%) Improved documentation Ambulatory CDI Results CMS HCC and Rx HCC captured: 1,030 Problem list updates made: 1,405 Able to graduate providers out of routine review Changes in template use Better relationships with providers 75 25

26 76 Next Steps Expand to all primary care Collaborate with revenue integrity advisors and coding and documentation specialists to provide education on E&M coding Continue to work with our health plan to better estimate our return on investment Conclusion Embarking on an ambulatory CDI journey is imperative Decide what methodology fits your practice model best Establish leadership Understand it is a team effort Find ways to engage providers Be open to feedback 77 Thank you. Questions? MSAlvara@gundersenhealth.org JMConroy@gundersenhealth.org AJBenzing@gundersenheatlh.org In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section at the front of the program guide