Quality Reporting in the Public Domain

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Ella Welch
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1 Quality Reporting in the Public Domain

2 Disclaimer This material is designed and provided to communicate information about inpatient coding, clinical documentation, and/or compliance in an educational format and manner The author is not providing or offering legal advice but, rather, practical and useful information and tools to achieve compliant results in the area of clinical documentation, data quality, and coding Every reasonable effort has been taken to ensure the educational information provided is useful and accurate Applying best practice solutions and achieving results will vary in each hospital/facility and clinical situation 2

3 Objectives Identify sources in the public domain reporting quality measures Understand the role of documentation and coding in the outcomes of public reporting Incorporate strategies into the workflow to achieve the appropriate outcomes 3

4 Impact of Documentation Clear, complete, timely and accurate documentation has a significant impact on many facets of fiscal and operational data that will continue to increase with healthcare reform Severity of Illness and Risk of Mortality Reimbursement RAC Audits and Compliance Documentation Medical Necessity and Length of Stay Present on Admission and HACs Profiling Hospital and Physicians 4

5 Hospital Data in the Public Domain Healthgrades Hospital Compare (CMS.gov) American Hospital Directory Consumer Reports The Leapfrog Group Hospital Safety Score Truven Health Analytics 100 Best Hospitals US News & World Report Best Hospitals 5

6 Healthgrades Hospital Rating System Top 50 hospitals identified with a gold star Top 100 hospitals identified with a silver star Patient Experience Compares the selected hospital to the national average Patient Safety Ratings Better than expected As expected Worse than expected Clinical Quality Better than expected 5 stars As expected 3 stars Worse than expected 1 star 6

7 Hospital Compare (CMS.gov) Debut of the Five Star Rating System, July 27, stars 102 hospitals 4 stars 934 hospitals 3 stars 1,770 hospitals 2 stars 723 hospitals 1 star 133 hospitals Hospital Profile General information Patients experiences Timely and effective care Complications Readmissions and deaths Use of medical imaging Payment and value of care 7

8 American Hospital Directory Patient Experience Rating (HCAHPS) 5 star rating system Joint Commission Accreditation Status TPS (Total Performance Score) Quality Score Four Domains Impacting the TPS Score The Clinical Process of Care Domain Patient Experience of Care Domain Outcome Domain Efficiency Domain 8

9 Consumer Reports Safety Score Scale of Hospital Acquired Infections Unnecessary readmissions Complications Communication about new medication and discharge instructions Appropriate use of scanning 9

10 The Leapfrog Group Top Hospitals Urban Hospitals Rural Hospitals Children s Hospitals Infections and Injuries Central Line Infection in ICU Urinary Catheter Infection in ICU MRSA Infection C Diff Infection Surgical Site Infection Following Major Colon Surgery 10

11 Leapfrog s Hospital Safety Score Hospital Score A, B, C, D, F Infections measured MRSA Infection C. diff Infection Infection in the blood during ICU stay Infection in the urinary tract during ICU stay Surgical site infection after colon surgery Problems with Surgery Dangerous object left in patient s body Surgical wound splits open Death from serious treatable complications Collapsed lung Serious breathing problem Dangerous blood clots Accidental cuts and tears 11

12 Truven Health Analytics 100 Best Hospitals 100 Top Hospitals Everest Award Major Teaching Hospitals Teaching Hospitals Large Community Hospitals Medium Community Hospitals Small Community Hospitals Key Performance Measures Risk-adjusted mortality index (in-hospital) Risk-adjusted complications index Risk-adjusted patient safety index 30-day mortality rate HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) score indicating patient ratings of overall hospital performance 12

13 US News & World Report Best Hospitals Best Hospitals Hospital Rankings by Specialty Hospital Rankings by Metro Areas and States Best Children s Hospital Rankings Healthcare of Tomorrow Common Care Ratings by Procedure and Condition Key Performance Measures Outcomes Patient Safety 13

14 Risk Adjustment Many different risk adjustment systems and methodologies CMS Healthgrades US News & World Report Best Hospitals Truven Health Analytics MIDAS Premier APR DRG SOI/ROM HCC Complete and specific documentation will contribute to ANY risk adjustment methodology 14

15 National Depth of Coding Trends Maryland Virginia Michigan North Carolina Wisconsin Maine Ohio Washington Kentucky West Virginia Arizona Indiana Illinois Utah Colorado Missouri Delaware Oregon South Carolina Nevada Minnesota Connecticut Rhode Island Texas Montana Tennessee Idaho Georgia Nebraska Vermont New Hampshire Pennsylvania Massachusetts North Dakota California Alabama Alaska New Jersey Florida Oklahoma Louisiana Hawaii South Dakota New York New Mexico Kansas Wyoming Arkansas Mississippi Iowa

16 Capturing Other (Additional) Diagnoses Re-visit UHDDS Definition Any condition that is documented by a treating physician, and: Clinically evaluated; or Diagnostically tested; or Therapeutically treated; or Causes an increase in LOS or nursing care Note: In addition to being documented by the physician, only one of the criteria above must be met in order for a condition to be considered a secondary diagnosis 16

17 Types of Quality Measures Active Hospital must collect data from medical record and submit data Used for Core Measures & CDC/NHSN Healthcare-associated Infections Complex abstraction rules; time consuming Hospital has generous amount of time for re-reviews and validation Passive Claims-based Used for Mortality, Readmission, AHRQ Patient Safety Indicators (PSI), Hospital Acquired Conditions (HAC) Based strictly on coding/claims data Less opportunity for re-reviews and validation 17

18 Hospital Readmissions Reduction Program Readmission Measures Acute myocardial infarction (AMI) Heart Failure (HF) Pneumonia Chronic obstructive pulmonary disease (COPD) Total hip arthroplasty/total knee arthroplasty (THA/TKA) Coronary Artery Bypass Graft (CABG) Surgery 18

19 Hospital Acquired Conditions (HAC) Original HACs Reduces severity of an individual MS-DRG Relatively small impact HAC Reduction Program Financial penalty for lowest performing hospitals Hospitals performing in the lowest 25% will have a 1% reduction in Medicare DRG revenue 19

20 Hospital Acquired Conditions (HAC) Domain Details Domain 1 FY15: 35% FY16: 25% FY17: 15% AHRQ Patient Safety and Adverse Events Composite PSI 03 Pressure Ulcer Rate PSI 06 Iatrogenic Pneumothorax Rate PSI 08 In-Hospital Fall with a Hip Fracture Rate PSI 09 Perioperative Hemorrhage or Hematoma Rate PSI 10 Postoperative Acute Kidney Injury Requiring Dialysis Rate PSI 11 Postoperative Respiratory Failure Rate PSI 12 Postoperative Pulmonary Embolism (PE) or Deep Vein (DVT) Rate PSI 13 Postoperative Sepsis Rate PSI 14 Postoperative Wound Dehiscence Rate PSI 15 Unrecognized Abdominopelivc Accidental Puncture/Laceration Rate 20

21 Hospital Acquired Conditions (HAC) Domain Details Domain 2 FY15: 65% FY16: 75% FY17: 85% CLABSI (Central line associated blood stream infection) CAUTI (Catheter associated urinary tract infection) SSI (Surgical site infection) colon and abdominal hysterectomy MRSA bacteremia C difficile infection 21

22 Hospital Acquired Conditions (HAC) Financial Impact Penalty only Based on combined domain scores All hospitals in lowest performing quartile have 1% penalty Total Medicare DRG revenue 22

23 HAC Documentation Strategy Appropriate documentation and coding of complication Clinical indicator support Condition ruled out Contradictory information Appropriate assignment of present on admission indicator Signs and symptoms on admission Timing of labs and diagnostic tests 23

24 Improvement Strategies - Documentation Present on admission Y condition was present on admission N condition was NOT present on admission W provider is unable to clinically determine whether condition was present on admission or not U documentation is insufficient to determine if condition is present on admission E diagnosis is exempt from POA reporting W is treated the same as Y by CMS 24

25 Querying in the HAC World There should NEVER be a consideration of: Will I get a better financial outcome if it s a POA of N or POA of Y? Do you have an escalation policy? Very helpful when querying to confirm a diagnosis or when clinical indicators are not present 25

26 Other Opportunities Review to ensure accurate information is captured Discharge Disposition Admission Source Nature of Admission 26

27 Strategy for Success HIM/ Documentation Nursing Finance Medical Staff Quality/PI 27

28 Improvement Strategies Education Leadership Financial impact Resources Front-line staff Coding and documentation professionals Methodology and opportunities Medical staff Documentation guidelines Clinical definitions Ongoing education 28

29 Improvement Strategies Oversight Education Data Analysis Medical Record Review 29

30 Develop Team Approach Build alliances and work as a team to achieve successful outcomes Health Information Management Coding Department Clinical Documentation Department Patient Access Denials Management Quality Department COMMUNICATE COMMUNICATE COMMUNICATE 30

31 CDSs and Coders Partners in Success Develop joint education for CDSs and coders Review clinical scenarios Review Coding Clinics and annual coding updates Complete pre-bill record reviews Understand what queries are generated retrospectively and generate the queries concurrently when possible Reconcile concurrent worksheets with the final coding This should be approached as a learning opportunity 31

32 Overall Clinical Documentation Review Strategy Develop a holistic and comprehensive approach to record reviews Focus on the on record as a whole and the interdependence of each component Understand the evolution and interplay of all diagnoses Follow up reviews are critically important 32

33 Comprehensive and Holistic Approach for Record Reviews Clinical Indicators Diagnosis Diagnosis Clinical Indicators Present on Admission (POA) NO MORE NO LESS 33

34 THANK YOU...QUESTIONS? Joni Dion, RHIA, CDIP, CCDS, CPC, CRC AHIMA Approved ICD-10-CM/PCS Trainer (614) Bonnie Peters, CCDS, CDIP, CCS-P, CRC, COC, CDC-I AHIMA Approved ICD-10-CM/PCS Trainer (505)

35 References Healthgrades American Hospital Directory The Leapfrog Group Hospital Safety Score

36 References Medicare Hospital Compare Quality of Care Medicare.gov Truven Health Analytics 100 Best Hospitals US News & World Report Best Hospitals Consumer Reports Hospital Agency for Healthcare Quality and Research

TABLE 3c: Congressional Districts with Number and Percent of Hispanics* Living in Hard-to-Count (HTC) Census Tracts**

TABLE 3c: Congressional Districts with Number and Percent of Hispanics* Living in Hard-to-Count (HTC) Census Tracts** living Alaska 00 47,808 21,213 44.4 Alabama 01 20,661 3,288 15.9 Alabama 02 23,949 6,614 27.6 Alabama 03 20,225 3,247 16.1 Alabama 04 41,412 7,933 19.2 Alabama 05 34,388 11,863 34.5 Alabama 06 34,849 4,074