Describe the process for implementing an OP CDI program

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1 1 Outpatient CDI: The Marriage of MACRA and HCCs Marion Kruse, RN, MBA Founding Partner LYM Consulting Columbus, OH Learning Objectives At the completion of this educational activity, the learner will be able to: Identify what an HCC is and how CMS uses it to measure severity Identify what MACRA means and how it impacts the movement to physician value based purchasing Verbalize a high level understanding of data that can be used to measure OP CDI ROI Describe the process for implementing an OP CDI program 2 3 1

2 4 Polling Question #1 Where are you in the OP CDI decision process? We have not thought about it, or we have determined that our institution will not benefit from OP CDI We believe we need an OP CDI program, but are not sure where to start We are actively performing research to determine whether we need an OP CDI program We have determined our institution needs OP CDI and are trying to figure out how to implement it We are currently implementing OP CDI, or we have a fully functioning OP CDI program Why OP CDI Is a Hot Topic More than the need for consulting firms to sell services 5 Why OP CDI? HCC Payment Model The Hierarchical Condition Category (HCC) model is the heart of the Centers for Medicare and Medicaid Services (CMS) methodology for determining capitated payments for the Medicare Advantage program, other Medicare, and payer programs. This model identifies individuals with serious or chronic illness and assigns a risk factor score to the person based upon the individual s health conditions, identified through the diagnoses submitted by providers. MACRA The Medicare Access and CHIP Reauthorization Act (MACRA) will replace the fee for service reimbursement model with a new two track risk based reimbursement system. HCC methodology will be incorporated into the calculations regardless of the reimbursement track chosen. brief/medicare advantage 2016 spotlight enrollment market update/ 6 2

3 7 What Is an HCC? CMS introduced CMS HCCs in 2004 as a methodology to measure risk Implemented as a means to ensure payment to Medicare Advantage plans is appropriate relative to the risk and cost of the patients covered Pertinent ICD 10 CM diagnoses are grouped into 79 disease categories As of February 2017, CMS is using V22 What Is an HCC? While a patient may be assigned multiple HCCs, the system is still hierarchical in nature. For example, diabetes will be assigned to one of three HCCs depending upon the manifestations a patient has The hierarchy methodology assigns the HCC that represents the most severe manifestation treated For non related disease categories, HCCs accumulate For example, a patient with diabetes and cancer will receive two HCCs 8 What Is an HCC? Each HCC is assigned a Risk Adjustment Factor (RAF) numeric value The total RAF score for a patient is based on three elements: 1. Age & sex 2. Medicaid status & Medicare disability eligibility 3. Chronic disease (CMS HCCs) Elements 1 and 2 are typically 45% 50% of the total RAF score 9 3

4 10 HCC/RAF Score Change Example No HCC Diagnoses Normal Point of Care Coding & Documentation After OP CDI 76 y.o. female y.o. female y.o. female Not Medicaid eligible 0.00 Not Medicaid eligible 0.00 Not Medicaid eligible 0.00 Diabetes Diabetes w/ renal CKD 0.00 CKD IV Heart failure, unspecified Chronic dyst/syst. CHF DM + CHF + renal RAF RAF RAF Estimated annual $2,536 Estimated annual $6,424 Estimated annual $17,384 payment payment payment What Does This Mean? Risk adjustment scores are higher for a patient with a greater disease burden and lower for a healthier patient HCC coding is prospective in nature; the work done this year establishes the RAF (and subsequent funding) for next year Chronic conditions must be reported once per year Each January 1, the HCC slate is wiped clean Medicare patients have zero HCCs until diagnosis codes are reported on claims Payments are generally adjudicated quarterly 11 What Does This Mean? Physicians that perform point of care coding must be well educated in HCC specificity Not all HCCs are OP situations Some diagnoses that trigger HCC payments are only treated in an inpatient setting These HCC diagnoses may not be the principal diagnosis, and many aren t on the CMS CC/MCC list HCCs audits have shown most hospitals and OP clinics underbill HCCs 12 4

5 13 HCC Financial Opportunity Potential Realization Revenue 25% $2.1M 50% $4.3M 75% $6.4M Results typical for a full service hospital system with 20 family practice clinics and a small number of specialty clinics Documentation/Coding Issue Coding specificity/hcc assignment opportunity Codes that require additional diagnoses to explain the full severity of the patient *Proprietary data analysis utilizing CMS HCC/RAF version 22 and average national payment of $8K per 1.0 of RAF. Based on 11 months of claims data (October 1, 2015 September 31, 2016). *Total Potential Revenue $5.7M $2.8M $8.5M MACRA Accelerating physician value based payments 14 What Is MACRA? MACRA contains language implementing the physician quality payment program for traditional Medicare plans Physician value based purchasing (VBP) was part of the Affordable Care Act (ACA) Physician payment based more on quality and less on quantity MACRA accelerated physician VBP and changed the methodology For this reason, plans to repeal and replace the ACA are not likely to eliminate MACRA 15 5

6 16 What Is MACRA? MACRA eliminated the Sustainable Growth Rate methodology for yearly increases to Medicare B professional provider fees Impacts reimbursement rates starting 1/1/2019; however, 2017 data must be submitted MACRA combines the previous meaningful use, Physician Quality Reporting System, and Value based Modifier initiatives into one composite score system Adds an additional category called Improvement Activities Providers can receive up to 100 points in these four areas Whom Does MACRA Impact? Exempt providers: Provider practices that generate less than $30K per year in Medicare Part B payments or have fewer than 100 unique traditional Medicare patients New Medicare enrolled MIPS eligible clinicians Providers who have not previously submitted claims under Medicare as an individual, an entity, or a part of a physician group or under a different billing number or tax identifier Non exempt providers: All specialties Hospital based clinicians Non patient facing eligible clinicians CMS is establishing a process to apply alternative measures for non patient facing clinicians 17 MACRA: Two Pathways for Payment Merit based Incentive Payment System (MIPS) Quality: Choose up to six quality measures that best reflect their practice specialty and report these to CMS. Improvement Activities: There is a list of 90 activities to choose from. Advancing Care Information: This section focuses on EHR interoperability and information exchange. Resource Use: CMS will use claims data to measure risk adjusted cost. Risk is measured using the CMS HCC model. Advanced Alternative Payment Model (APMs)* Medicare Shared Saving Programs (MSSP) tracks 2 and 3 Next Generation ACOs Comprehensive ESRD Care Comprehensive Primary Care Plus Oncology Care Model * CMS has established financial risk and qualifying professional thresholds that must be met in addition to being part of the payment models above 18 6

7 19 How MACRA Impacts Payment Transition to MIPs for the 2017 data collection period This is the 2019 payment ONLY Four options for MIPs data submission Zero data = 4% penalty Test data = 0 adjustment Continuous 90 day data = neutral or small positive payment adjustment Full year data = moderate positive payment adjustment MSSP and Next Generation ACOs not meeting AAPM qualifying thresholds must still submit a full year of data due to their previously agreed upon reporting structure How MACRA Impacts Payment A provider s MIP score will be compared with other participants to create a threshold score In 2020, clinicians will receive a 5% positive or negative payment adjustment Those who score at the threshold will remain neutral Those who score above the threshold will receive a positive payment adjustment Those who do not submit data or who score below the threshold will receive a negative payment adjustment The 5% adjustment will gradually increase to 9% in 2022 Those who participate in the APMs will receive an automatic 5% bonus in addition to the MIPS payment adjustment 20 OP CDI The elephant in the room 21 7

8 22 Provider View of HCCs & MACRA How to Define OP CDI While the concept may seem simple, there is not a one size fits all solution Questions to guide the design of an OP CDI solution How are diagnosis codes assigned for outpatient clinic visits? What percentage of your patients are Medicare Advantage or in a accountable care organization (ACO) risk sharing plan? What is your rate of NCD/LCD (national and local coverage determinations) medical necessity and/or clinical denial issues? How much rework is occurring due to inappropriate use of unspecified codes? What is the root cause? 23 How to Define OP CDI An OP CDI program must be an all encompassing and data driven solution that addresses the impact of deficient documentation and coding across the entire billing continuum OP CDI must leverage all available people, processes, and technologies to enhance provider workflow and drive results All individuals involved in the OP CDI process should work to the height of their licenses 24 8

9 25 How to Eat the OP CDI Elephant Due to the volume of visits, OP CDI must look beyond traditional concurrent review and query processes and instead: Leverage EMR technology and data analytics to drive process improvement Employ process improvement and change management techniques to produce results Use of CDI staff to read every note and query should be a solution of last resort. How to Eat the OP CDI Elephant OP CDI needs to be multifocal. The staff must have a broader revenue cycle focus and be strategic thinkers. Understand OP coding rules and billing regulations Be able to analyze and monitor metrics, perform root cause analysis, comprehend the strategic use of data, interpret regulations, create education, and communicate to large and small groups Understand hospital technology and how it can be used to improve the documentation and coding process to promote long term monitoring/process improvement 26 Where to Start: Assessment Analyze one year of post ICD 10 CM OP claims to identify, quantify, and prioritize OP services that would benefit from CDI involvement HCC capture Unspecified codes Technical and clinical denials Medical necessity denials Perform interviews and on site visits to understand process and root cause 27 9

10 28 Where to Start: Assessment Determine if chart review is necessary Based on interviews and visits, do you still need to review charts to determine root cause? Based on assessment findings, determine: What OP CDI methodology should be implemented SWOT analysis (cost/benefit) Potential ROI Report findings Sample Data Analysis Compare overall E/M levels reported to optimal benchmarks. Drill down to the service line and individual physician level. 29 Sample Data Analysis Analyze E/M levels to HCCs billed to identify potential areas of under or overdocumentation and coding 30 10

11 31 Sample Data Analysis Average cost per beneficiary to HCC to evaluate physicians cost vs. severity of illness Implementing the OP CDI Solution Program Infrastructure Workflow Enhancement Training and Education Analytics Build Data Monitoring Ongoing Education 32 Implementing the OP CDI Solution Identify the executive sponsor and project lead Define program goals and population ED and infusion areas? (charge capture risk) Radiology? (medical necessity risk) All vs. some owned physician practices? Staffing decisions/budget RN and/or OP coder? Data analyst? Build job descriptions. Recruitment of staff How many and what mix? Identify internal resources in the clinics

12 34 Implementing the OP CDI Solution Performance monitoring metrics/dashboard creation What decision support tools are available? What data is available? How can distribution and education be automated? HCC education and training plan Education to train OP and IP CDI staff Targeted education for physicians Updates due to coding, HCC, and other rule changes EMR/workflow optimization Analyze tools used for POS coding and determine best methodology Implementing the OP CDI Solution Process flows and continuous process improvement plan OP CDI will be an ongoing process; create flows to show the 5 W s Department policy and procedure Communication plan Roll out plan for leadership, physicians, clinic, and revenue cycle staff Compliance auditing and monitoring Monitor dashboard outliers 35 Teach Your Provider Staff to Fish Review EMR favorites lists to ensure choices support accurate code assignment Give provider specific feedback and education Articulate the WIFM Share baseline measures with problematic physicians, showing how they compare to their peers and what they can do to improve Recognize and celebrate improvements 36 12

13 37 Bringing the Solution Back to the Physicians OP CDI results and benefits: Streamlines physician administrative responsibilities for ICD 10 documenting, coding, and billing through workflow simplification, process enhancement, training, and support Reshapes electronic billing tools for an integrated lasting solution Implements a sustainable solution that strengthens compliance, governance, and appropriate reimbursement Improves physician satisfaction with documentation, coding, and billing processes, which enables more time for patient care Promotes all staff working to the height of their license Thank you. Questions? mkruse@lymconsulting.com 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