Clinical Documentation Improvement: Best Practice

Transcription

1 Revenue Cycle Solutions Consulting and Management Services Clinical Documentation Improvement: Best Practice Our mission: To help you finance yours.

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5 5 About the Presenter Linnea Thennes, RN, BS, CCDS, CCS Linnea Thennes is an Associate Director with The Advisory Board Company s Revenue Cycle Solutions Consulting and Management division. In this capacity, Ms. Thennes provides clinical documentation improvement expertise to Members across the country with respect to PDI data analysis, leads one on one physician engagement meetings, and serves as a subject matter expert on all things CDI. Ms. Thennes has over 30 years of professional experience in health care including emergency medicine, critical care, nursing education and management. In addition to her clinical experience, she has been immersed with clinical documentation improvement since 2007, implementing and managing programs located in Illinois. Working collaboratively with physicians and administration, Ms. Thennes provided information and education to the medical staff regarding severity of illness and risk of mortality to ensure complete, compliant, and quality documentation. A registered nurse and graduate of the University of St. Francis with a Bachelor of Science degree, Ms. Thennes also completed clinical documentation improvement training from 3M, JA Thomas and Deloitte. She is a Certified Clinical Documentation Specialist (CCDS) and an active member of the Association of Clinical Documentation Specialists (ACDIS); a Certified Coding Specialist (CCS) and member of the American Health Information Management Association (AHIMA).

6 6 Session Objectives After attending this session, you will: Identify key components of successful CDI programs Understand why CDI programs need to be both financial and quality centric. Explore strategies identifying risk areas that may be affected by quality penalties, denial, and audit take-backs. Factors to consider before expanding CDI to the outpatient space.

7 7 Refocusing CDI to Prepare for New Payment Models Hospitals, physicians and patients are impacted by clinical documentation Communication Outcomes Credentialing Revenue Documentation Quality Performance Compliance Medical Necessity

8 8 Translating Physician Documentation into Data Demographics Admitting Diagnosis Principal Diagnosis Secondary Diagnoses Procedures Diagnostic Testing Inpatient Clinical Documentation ImprovementIn Quality Case Management Outpatient Clinical Documentation Diagnostic Related Group (DRG) Comorbid/ Major Comorbid Conditions (CC/MCC) Geometric Mean Length of Stay (GMLOS) Relative Weight (RW) Severity of Illness (SOI) Risk of Mortality (ROM) Hospital Acquired Conditions (HACs) Present on Admission (POA) Quality Metrics Medical Necessity (MN)

9 Framework for Evaluation: Best Practices for Program Success 9 1 Define Mission, Goals & Department Structure 2 Staffing, Productivity & CDI Roles 3 Efficient and Consistent Process Flow 4 Strong Relationship and Rapport Record Review Query Secure Responses 5 Measurement & Accountability

10 10 Pillar One Define Mission, Goals & Department Structure: focus is balanced on finance and quality.

11 11 Program Scope Will Define Focus of Reviews CDI Program Objectives & Focus Measures CDI Program Objectives Optimize Payments Protect Payments Quality Payments & Quality Profiling 1 MS-DRGs 2 nd CC/MCC: RACproof Charts HACRP (PSI#90) Risk CDI Program Measures APR-DRGs HVBP Mortality Risk HRRP Readmission Risk Fee-for-Service Quality-Based Payments 1) Hospital-Acquired Condition Reduction Program; Hospital Value-Based Purchasing Program (HVBP); Hospital Readmission Reduction Program (HRRP)

12 12 Pillar Two Staffing, Productivity & CDI Roles: optimal staffing is a combination of dedicated resources alongside a network of stakeholders and champions.

13 CDI Operational Review #2: Staffing, Productivity & CDI Roles 13 Program Staffing and Oversight Best Practice Immediate Reporting Relationships for CDI Programs 7% Quality 11% Finance 17.9% Coding Other 9% n=75 29% 27% Case Management Health Information Management (HIM) Setting Expectations An optimal CDI Leadership structure helps to establish rigorous performance expectations, supports cultural transformation and drives change Engage clinical leadership in setting expectations for physician participation and responsiveness Set internal expectations for annual program revenue impact Monitoring Performance Provide ongoing reports on key performance indicators to both staff and executive leadership Track annual program impact against expectations Review individual CDI Specialist performance profiles Coordinate information on denials, quality, and audit trends to guide CDI team towards high-priority risk areas Reviewing Program Resources Assess CDI staffing levels annually Evaluate effectiveness of existing investments in educational activity, technology, vendor support Explore additional investment needs (e.g., staffing, training, IT, external support) Source: Financial Leadership Council 2014 CDI Benchmarking Survey.

14 14 Pillar Three Efficient and Consistent Process Flow: processes are standardized to maximize efficiency and consistency. Record Review Query Secure Responses

15 15 Process Flow Maps CDI Workflows

16 16 Hardwired CDI Escalation Policy Commonly Used Escalation Policy

17 17 Pillar Four Strong Relationship and Rapport: position CDI specialists as well-respected translators between clinicians, coders and key stakeholders.

18 CDI Operational Review #4: Strong Relationship and Rapport 18 Indicators of an Engaged Medical Staff Seeks guidance proactively from CDI staff on documentation issues Has adopted and understand the most important documentation concepts for their service area Requires more novel queries Advocates for peers to improve documentation Seeks administrative support of increase documentation aids (e.g., NLP software, ongoing education)

19 CDI Operational Review #4: Strong Relationship and Rapport 19 Formalize Strategy for Ongoing, Proactive Education Targeted Engagement Select top-admitting, highimpact physicians for targeted 1-on-1 training Goal: Providers acknowledge value of their written word and commit to CDI process Phase 1: Phase 2: Ongoing Education CDI teams use data & actual patient examples to direct focus of ongoing education Goal: Facility MD Champions and engaged advocates ensure regular access to key service lines and staff Targeted Engagement Specialty-Specific Education Reward Performance Phase 4: Phase 3: Benchmark Progress Providers are recognized for documentation excellence by executive staff, physician incentives, and more Goal: Analyze Data, identify physician outliers, and develop action plan for return to Phase 1 Public Recognition Consistent Feedback Incorporate documentation metrics from analytical tools, benchmarking analyses & CDI reports into specialty-specific score cards Goal: CDI teams share data and prioritized areas for improvement, motivating continued program involvement

20 20 Pillar Five Measurement & Accountability: range of metrics to measure performance on the goals identified in the mission.

21 21 Which Metrics are Right? Do the Key Performance Metrics Support your Program Goals? Process Query rate Query response rate Query agreement rate Financial Case mix index CC/MCC capture rate Financial impact per query Quality Quality outcomes Expected quality outcomes Length of stay

22 22 CDI Benchmarking Metrics Staffing/ Review Rates Metric Industry Median High Performing Initial chart reviews per day Follow-up chart reviews per day Total chart reviews per day % of identified records reviewed >60% >80% % of all inpatient discharges reviewed (not an industry standard metric) Average time from inpatient admission to initial review 35%-40% hours hours Average time between follow-up reviews hours hours % of initial reviews with one or more follow-up reviews 60%-80% 100% Average number of follow-ups per review

23 23 CDI Benchmarking Metrics Querying and Reconciliation Metric Industry Median High Performing Query rate (total # of queries/total # of cases reviewed) 25% 40% Queried case rate (total # of cases with 1 or more queries/total # of cases reviewed) % of cases with "integrity/quality" impact queries achieved more accurate, specific, complete medical record but no direct financial impact such as any DRG shift (MS, APR, AP) % 25% 10% 15% Coder match rate >60% >70% Financial impact query rate (# of queries that resulted in DRG change/total # of queries) Total potential financial impact (lost) due to "no response" to query 10%-15% 25% goal = $ 0

24 24 CDI Benchmarking Metrics Physician Response Metric Industry Median High Performing Physician response rate 80%-85% >90% Physician agreement rate 80%-85% >85% Average physician query response time 2-3 days <2 days

25 25 Making Progress Toward Value-Based Payment In April 2016, The Health Care Transformation Task Force reported that 41% of both its providers and payers members business were in value-based payment (VBP) arrangements at the end of 2015.Task force members¹ have pledged to have 75% of their business in VBP by % 30% 41% Value based payments arrangements² 1) Task Force consists of 26 providers and 6 major payors 2)Calculated as a percent of total business

26 26 New Payment Models Requires Refocus Most organizations narrowly focus clinical documentation improvement (CDI) efforts on either financial or quality goals, but must adjust to support both interests. Do not delay expanding the scope of your CDI program; our research indicates at least an 18 month timeframe to add capabilities or enhance effectiveness.

27 Protect Captured Revenue by Leveraging Quality Metrics 27 Expand CDI goals to focus on quality metrics that impact performance or influence penalties on risk adjustment measures such as hospital-acquired conditions (HAC), readmissions, or patient safety indicators.

28 28 HAC Reduction Program The HAC measures consist of two measure sets (Domains) Domain 1 - Composite Patient Safety Indicator (PSI) #90 Domain 2 - HAI (Hospital Acquired Infections) developed by the CDC e.g. CLABSI and CAUTI. Hospitals scoring in the top quartile (lowest performing 25%, for the rate of HACs) will have their total Medicare inpatient payments reduced by 1% HAC payment penalty adjustment would occur after base DRG payment adjustments are calculated for: Hospital Value Based Purchasing Program (HVBP) Hospital Readmissions Reduction Program (HRRP)

29 29 Hospital Acquired Conditions The hospital will not receive additional payments for these conditions if not present on admission (POA) These conditions are typically High volume High cost High volume and cost

30 30 Hospital-Acquired Conditions Include the following Conditions Foreign Object Retained After Surgery Air Embolism Blood Incompatibility Stage III and IV Pressure Ulcers Falls and Trauma Catheter Associated Urinary Tract Infection Vascular Catheter Associated Infection Manifestations of Poor Glycemic Control DVT/PE with Total Knee/Total Hip Procedures Surgical Site Infection Mediastinitis After CABG Bariatric Surgery Ortho Procedures of Spine, Shoulder, and Elbow Following Cardiac Implantable Electronic Device (CIED) Iatrogenic Pneumothorax w/venous Catheterization Procedures

31 31 CMS Readmissions Reduction Program Definition A readmission is defined as being an admission to an acute care hospital paid under the Inpatient Prospective Payment System (IPPS) within 30 days of a discharge from the same or another acute care hospital. CMS counts all readmissions to any short term acute care hospital within 30 days of discharge, with two exceptions: Planned readmissions Same day readmissions for the same condition to the same hospital

32 32 Don t Miss the Fine Print Readmissions Guidelines CMS considers unplanned readmissions for any reason (all cause) Patient s who are readmitted twice within 30 days are simply counted as having been readmitted An unplanned readmission is disruptive and costly regardless of cause An apparently unrelated readmission may represent a complication related to the underlying condition Restricting the outcomes to those readmissions that are directly related to the initial hospitalization may result in less meaningful measures

33 33 Expansion of CDI Services Lines in a Timely Manner Now that ICD-10 has passed, many CDI programs face the challenge of re-defining their mission going forward.

34 Outpatient Physician Payments Aligning to Value- Based Care 34 CMS s Proposed Physician Payment Model Beginning in 2017 MACRA Ruling Streamlines Quality Reporting Program PQRS, VBPM, MU, and CPIAs are consolidated into a single system Rewards Value- Based Care New framework for rewarding physicians for higher quality care by establishing two tracks for payment: Merit-based Incentive Payment System (MIPS), and Alternative Payment Models (APMs) Repeals Sustainable Growth Rate (SGR) formula Current methodology for determining updates to the Medicare physician fee schedule will be replaced with predictable payment increases

35 35 Outpatient CDI Program Challenges and First Steps Challenges Physician Practice buy in to an outpatient CDI program Outpatient Evaluation and Management (E/M) levels are not tied to acuity or specificity of diagnosis Ensuring accuracy and completion of patient charts in the ambulatory environment Projecting return on investment (ROI) Prioritization of targeted populations is challenging Benchmarking Risk Adjustment Factors (RAF Scores) Concurrent Review Timeliness Standardizing Query Process between inpatient and outpatient and other (Quality, Case Management, etc) Constraints of software applications interfacing with physician practices software Resource pool of Qualified Ambulatory CDI staff is limited First Steps Assess effectiveness of your inpatient CDI program against the 5 pillars Recommend inpatient program be optimized prior to moving into additional areas Review and update the mission and goals of the CDI program to include the goals of the outpatient program Leverage historical data in establishing ambulatory practice baseline metrics Identify outpatient CDI workflow and processes Identify outpatient query processes Focus outpatient CDI reviews on Risk Adjustment Factor (RAFs) score Identify tools and technology to assist in physician documentation

36 36 Revisiting Today s Key Learning Points 1 Identify key components of successful CDI programs 2 Understand why CDI programs need to be both the financial and quality centric. 3 4 Explore strategies identifying risk areas that will be affected by quality penalties, denial, and audit take-backs. Factors to consider before expanding CDI to the outpatient space.

37 37 Question and Answers If you have any questions, please submit them into the chat now.