May 2014 Lunch and Learn. Objectives

Transcription

1 May 2014 Lunch and Learn Summer Series VBP and HACs Objectives The attendee will be able to: Discuss - What is VBP, Who Participates, and What s at Stake List at least 3 quality and safety measures Explain what is a hospital acquired condition Describe the healthcare providers role in demonstrating safe and quality patient care Summarize the role of the coder in demonstrating safe and quality patient care 1

2 The Six Goals of the CMS Quality and Safe Patient Care Strategy 1. Make care safer by reducing harm caused in the delivery of care 2. Strengthen person and family engagement as partners in their care 3. Promote effective communication and coordination of care 4. Promote effective prevention and treatment of chronic disease 5. Work with communities to promote healthy living 6. Make care affordable Value Based Purchasing is a payment methodology that rewards quality of care through payment incentives and transparency. Value can be broadly considered to be a function of quality, efficiency, safety and cost. Healthcare providers are held accountable for the quality and cost of the health care services they provide by a system of rewards and consequences, conditional upon achieving pre-specified performance measure. 2

3 Mandatory Participation Hospitals serving Medicare beneficiaries Physician office settings Ambulatory Surgery Centers Hospice and Home Health Rehabilitation Hospitals (2016) Critical Access (2016) Value Based Purchasing

4 WHAT IS THE FINANCIAL IMPACT OF VBP? Withholding CMS reimbursement The VBP initiative is funded by withholding reimbursement from participating hospitals Diagnosis Related Group (DRG) payments FY % FY % FY % FY % FY % CMS estimated that in FY 2013, 50% of participating hospitals received a net increase in payments and 50% received a net decrease in payments 1% of DRG payments withheld from eligible hospitals is estimated at $850 million. VBP Impact 4

5 VBP Collateral Risk Financial Risks (Noted Previously) Operational and Reputational Risks Medical Malpractice/Litigation Underwriter / Carrier Issues Regulatory and Accreditation Impact Public Consumer Opinions Adverse Events/Mandatory Reportable Events Mortality and Morbidity Employees, Physicians, Residents, Students Satisfaction Scores Impact on Managed Care Contracting, Hospital Rating & Business Partner Relationships Quality and Safety Measures Hospital Acquired Conditions A Hospital Acquired Condition (HAC) is a medical condition or complication that a patient develops during a hospital stay, which was not present at admission. In most cases, hospitals can prevent HACs when they give care that research shows gets the best results for most patients. Are high cost or high volume or both, Result in the assignment of a case to an MS DRG that has a higher payment when present as a secondary diagnosis, and Could reasonably have been prevented through the application of evidencebased guidelines Patient Safety Indicators Patient Safety Indicators (PSIs), developed by the Agency for Healthcare Research and Quality (AHRQ), are administrative data based indicators that identify potential inhospital patient safety events. Our next Lunch and Learn will focus on the PSIs especially the composite PSI 90. 5

6 Claims Data How do we report HACs? Diagnostic Codes (ICD-9-CM) (CDC) are assigned to all conditions requiring clinical evaluation, therapeutic treatment, diagnostic procedure, extended length of stay, required additional nursing time and/or monitoring This is reported by individual occurrence and is used individually and aggregate. National Healthcare Safety Network (CDC) Evidence Based Screening Criteria No provider documentation required of the actual condition/diagnosis (provider documentation used for SSI and pneumonia) Based on clinical indicators in the medical record and laboratory findings This is reported by individual occurrence and is used individually and aggregate. HAC List Hospital Acquired Description Category ICD 9 CM code POA Indicator Foreign Objected Retained After Surgery N, U N, U Air Embolism N, U Blood Incompatibility Pressure Ulcer Stages III & IV Falls and Trauma Codes within these ranges N, U N, U N, U N, U N, U N, U N, U Fracture N, U Dislocation N, U Intracranial Injury N, U Crushing Injury N, U Burn N, U Electric Shock N, U Catheter Associated Urinary Tract Infection (UTI) N, U Addtl Criteria Also excludes the following from acting as a CC/MCC: 112.2, , , 590.2, 590.3, , 597.0, Vascular Catheter Associated Infections N, U * N,U * N,U local site skin infection Manifestations of Poor Glycemic Control N, U N, U N, U N, U N, U NHSN reporting also Includes SSI (colon and Hysterectomies), pneumonia as wells as c. diff and MRSA infections. Currently we have limited reporting capabilities for pressure ulcers. In ICD-10 the reporting capability greatly expands. 6

7 HAC List (continued) Hospital Acquired Description Category ICD 9 CM code POA Indicator Addtl Criteria Surgical Site Infection, Mediastintis, Following Coronary Artery Bypass Graft (CABG) Surgical Site Infection Following Certain Orthopedic Procedures Surgical Site Infection Following Bariatric Surgery for Obesity Surgical Site Infection following Cardiac Implantable Electronic Device Procedures (CIED) Deep Vein Thrombosis and Pulmonary Embolism Following Certain Orthopedic Procedures Iatrogenic Pneumothorax with Venous Catheterization N, U and one of the following procedure codes N, U and one of the following procedure codes N, U N, U N, U N, U * N,U * N,U N, U N, U N, U N, U *512.1 N, U and Principal Diagnosis and one of the following procedure codes and one of the following procedure codes 00.50, 00.51, 00.52, 00.53, 00.54, 37.80, 37.8, 37.82, 37.83, 37.85, 37.86, 37.87, 37.94, 37.96, 37.98, 37.74, 37.75, 37.76, 37.77, 37.79, &/or and one of the following procedure codes and procedure code Several HAC categories have additional criteria that must be applied when determining is this qualifies to be included as a HAC. If unsure research and utilize your industry experts for guidance: - Infection Prevention - Clinical Documentation Improvement - HIM Coding - Performance Improvement Why is Documentation Important? The importance of consistent, complete documentation in the medical record cannot be overemphasized. Medical record documentation from any provider involved in the care and treatment of the patient may be used to support the determination of whether a condition was present on admission. In the context of the official coding guidelines, the term provider means a physician or any qualified health care practitioner who is legally accountable for establishing the patient s diagnosis. These guidelines are not a substitute for the provider s clinical judgment as to the determination of whether a condition was/was not present on admission. The provider should be queried regarding issues related to the linking of signs/symptoms, timing of test results, and the timing of findings. 7

8 Case Example Pressure Ulcer 79 year old 105 lb. female transfer from OSH to AED on a back board. Hx: found down at home on concrete patio presumed fall from ladder Admitted on Day 3 of admission wound care was consulted and determined patient had a stage III pressure ulcer on the coccyx and stage II on the right trochanter. Are these pressure ulcers hospital acquired? Case Example - Pressure Ulcer What does the admission H & P state on this patient? Skin intact, warm and dry What does the admission nursing assessment reflect? Dark red area on coccyx and bruising on Rt trochanter with small abrasion. Braden score high risk Based on nursing documentation there is clinical evidence that a pressure area on the coccyx and rt trochanter was potentially present on admission. 8

9 Case Example CAUTI (Catheter Associated Urinary Tract Infection) AED patient arrived from NH with foley. Urinalysis revealed >100 WBC and large leukocyte esterase. Patient was admitted with ischemic stroke. Two days later a urine culture was obtained which grew e. Coli. Based on NHSN criteria this met the reporting criteria for a CAUTI. Clinically we can demonstrate this was probably POA but under VBP NHSN data is used for CAUTIs. Case example CLABSI (Central Line Associated Blood Stream Infection) Immunocompromised patient readmitted with urine culture for e. coli. Later in the stay blood culture and respiratory culture positive for e. coli. Patient had been on appropriate antibiotics. MD documented on day 30 of admission: e. coli sepsis blood culture from PICC line with e. coli. Is this a CLABSI? 9

10 Case example CLABSI Based on NHSN criteria this would not be reported. It is considered a secondary infection. What about from coded data? Is this due to the PICC line? Does the physician mean due to the PICC line or does he just reference the PICC line as the place the blood was drawn from? Conclusion Safe Patient Care is EVERYONE s responsibility Quality Patient Care is EVERYONE s responsibility Care must be documented accurately so that appropriate coding can capture the care provided which leads to accurate data capture and correct financial reimbursement. 10

11 References ACFactSheet.pdf Education/Medicare-Learning-Network- MLN/MLNProducts/Downloads/wPOAFactSheet.pdf Official ICD-9-CM Guidelines for Coding and Reporting Appendix I Next Session PSI Questions 11

12 Discussion & Questions 12