Alabama HIMA: Clinical Documentation Transformation April 14, 2016
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
Discussion Topics Evolution and Differences of DRG systems and the impact on clinical data Overview of APR DRG Methodology Public Reporting and Why it Matters Collaborate and Build a Team 3
Discussion Topics Evolution and Differences of DRG systems and the impact on clinical data History of DRGs MS DRGs APR DRGs Medical Record is the core / foundation for clinical data management RAC Audits Compliance Severity of Illness (SOI) and Risk of Mortality (ROM) Profiling Hospitals and Physicians Hospital Acquired Conditions Public Reporting and Why it Matters Healthgrades.com Hospitalcompare.gov Qualitycheck.org Data.gov Collaborate with Leadership to gain support for the CDI Program Establish a Steering Committee Establish an Operational Committee Select a Physician Champion 4
Brief History of DRGs American Health Information Management Association. Evolution of DRGs (updated). Journal of AHIMA (Updated April 2010) Copyright 2016 by the American Health Information Management Association. All rights reserved. 5
Medicare Severity (MS) DRGs MS DRGs were implemented October 1, 2007 to better recognize severity of illness The MS DRGs were a significant improvement but it does not account the actual complexity of the Medicare population Does not capture multiple additional comorbidities or complications MS DRGs have a three-tiered structure MCC CC Without MCC/CC In the public domain 6
3M APR DRGs: Beyond Resource Use Development of a new method and refinement to evaluate hospitals Evaluate hospitals across an extensive range of outcome and resource measures Evaluate variances in inpatient mortality rates Implement and support of critical pathways Identification of continuous quality improvement projects The need for a system to accurately capture Case Mix Complexity 7
3M APR DRGs Overview: All Patient Refined Diagnostic Related Group Developed by 3M AP DRGs used initially as the base Yale s R DRGs incorporated PM DRGs (pediatric modification) National Association of Children s Hospitals and Related Institution were integrated Much more clinically uniform and similar Calculates a severity of illness (SOI) Calculates a mortality risk (ROM) Takes resource intensity into consideration Captures differences in the patient s complexity of illness 8
3M APR DRGs http://solutions.3m.com/wps/portal/3m/en_us/health-information-systems/his/productsand-services/products-list-a-z/apr-drg-software/ 9
Factors Used to Calculate 3M APR DRGs Case Mix Complexity Severity of illness Resource intensity Need for intervention Factors used to Calculate APR DRGs Risk of mortality Prognosis Treatment difficulty 10
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 16.00 National Depth of Coding Trends 15.28 15.00 14.00 13.28 13.00 12.00 11.66 11.00 10.00 9.00 8.00 11
Definition of Severity Severity of illness (SOI) is defined as the degree of physiological decomposition of body systems What does this mean? Severity describes how ill a patient is and what resources are required to treat a patient Risk of mortality (ROM) is the likelihood of dying Resource Intensity is the relative volume and types of diagnostic, therapeutic and bed services used in the management of a particular disease 12
APR DRG Levels Each SDx* SOI and ROM value Each DRG SOI and ROM value 25 MDCs 2 Subclasses Severity of Illness [SOI] Risk of Mortality [ROM] 1 2 3 4 Minor Moderate Major Extreme Benefits Adjust for SOI Reimburse appropriately 311 APR DRGs + 3 Unrelated APR DRGs 2 Invalid APR DRGs * Some exclusions apply 13
Severity DRG Decision Flow MDC Assignment PDx Selection SDx Selection Valid Procedure? SDx SOI SDx ROM 1 Minor 2 Moderate 3 Major 4 Extreme Surgical Severity DRG Medical Severity DRG Interaction between PDx, each SDx SOIs and Procedures Severity DRG DRG SOI DRG ROM 1 Minor 2 Moderate 3 Major 4 Extreme 14
Key Concepts: Overall SOI Assignment Overall SOI assignment All ICD-10-CM diagnosis codes have a default severity of illness (SOI) level Minor (1) Moderate (2) Major (3) Severe (4) Secondary diagnosis (SDx) SOI levels do not count when the diagnosis is used as the principal diagnosis (PDx) UTI as SDx = SOI 2 UTI as PDx = APR DRG 463: Urinary Tract Infection - SOI of 1 The default SOI maybe excluded, promoted, or demoted based on its relationship with the principal diagnosis (PDx) 15
Approach to 3M APR DRGs Rerouting Logic Rerouting Logic Unique to APR DRGs Overly broad principal diagnosis Sequencing of principal and secondary diagnosis is blurred or indistinct Re-routing logic reassigns the patient to a new APR DRG or SOI Within the same MDC (Within MDC Rerouting) Across MDCs (Across MDC Rerouting) 16
Secondary Diagnosis SOI Adjustment: Promotion Patient 1 Patient 1 Code Description SOI PDX I63.9 Cerebral Infarct Code Description SOI PDX I63.9 Cerebral Infarct SDx A41.9 Sepsis, NOS 3 SDx A41.5 1 Sepsis due to E. Coli 4 SDx J69.0 Aspiration PNA 4 SDx N39.0 UTI 2 SDx A49.8 E. Coli 1 APR DRG 045: CVA w/ Infarct Severity Level: 3 (Major) MDC 001: Nervous System SDx J69.0 Aspiration PNA 4 SDx N39.0 UTI 2 SDx A49.8 E. Coli 1 APR DRG 045: CVA w/ Infarct Severity Level: 4 (Extreme) MDC 001: Nervous System Additional specificity of sepsis will promote or increase the SOI level 17
Secondary Diagnosis SOI Adjustment: Demotion Patient 1 Patient 1 Code Description SOI PDx I48.91 A-Fib SDx J90 pleural effusion 3 SDx J18.9 PNA 3 APR DRG 201: Cardiac Arrhythmia & Conduction Disorders MDC 5: Diseases & Disorders of the Circulatory System Code Description SOI PDx I50.9 CHF SDx J90 pleural effusion SDX J18.9 PNA 3 PPx 0W9B3ZZ Thoracentesis APR DRG 194: CHF 2 MDC 5: Diseases & Disorders of the Circulatory System The SOI is demoted or decreased in this example because pleural effusion is typically seen in CHF patients; however, in this example, the patient had a thoracentesis so we can report the pleural effusion. (AHA Coding Clinic 3 rd Quarter 1991 pg. 19 20) 18
Age Modification: Secondary Diagnosis SOI Impact Age Modification Diagnosis Default SOI Criteria Age SOI Impact Dehydration 1 70 y/o 2 ESRD 2 < 18 y/o 3 Hematuria 1 < 1 y/o or 80 y/o 2 Cellulitis Upper 1 2 Limb 65 y/o 19
Comparison of MS DRG to APR DRG DIAGNOSIS ICD-10 Code MS DRG APR DRG Hyponatremia E87.1 CC SOI 2 Hypernatremia E87.0 CC SOI 3 History of pancreas transplant Combined systolic and diastolic heart failure, acute on chronic Z94.83 CC SOI 3 I50.43 MCC SOI 3 Acute renal failure N179 CC SOI 3 Pneumonia NOS J189 MCC SOI 3 UTI N390 CC SOI 2 CHF NOS I50.9 Not a CC/MCC SOI 2 Thrombocytopenia D69.6 Not a CC/MCC SOI 2
Diagnoses Potentially Missed Homelessness Z59.0 (1) Kidney transplant status Z94.0 (2) Dependence on supplemental oxygen Z99.81 (2) Liver transplant status Z94.4 (3) Dependence on respirator (ventilator) status Z99.11 (4) Colostomy status Z93.3 (1) Attention to colostomy Z43.2 (2) Nephrostomy status Z93.6 (2) Attention to nephrostomy Z43.6 (1) 21
Diagnoses Potentially Missed Morbid obesity due to excess calories E66.01 (2) Noncompliance with medications in psych patients (e.g. schizophrenia, unspecified Z91.14) (SOI 2 only in PSY PDx) Suicidal/Homicidal Ideation R45.851 (2) Awaiting organ transplant Z76.82 (3) Vitamin Deficiency E56.9 (2) Failure to Thrive (adult) R62.7 (2) Hypothermia, initial episode T68XXXA (2) 22
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 23
Hospital Data in the Public Domain healthgrades Hospital Compare (CMS.gov) American Hospital Directory The Joint Commission, Quality Check The Leapfrog Group Truven Health Analytics US News & World Report Best Hospitals Consumer Reports 24
PEPPER Resources PEPPER Program for Evaluating Payment Patterns Electronic Report PEPPER is an electronic data report that contains statistical claims data for MS DRGS at risk for improper payment due to billing, coding, and/or medical necessity The findings from PEPPER can be used to develop auditing and monitoring action plans PEPPER distributed quarterly for Short-term Acute Care Hospital through the Secure PEPPER portal or through QualityNet Compare Targets Report Compares the hospital s target discharges at the national and state level Identifies the hospital s outlier status as high, low, or into the expected range 25
Using PEPPER Example of Target Areas Simple Pneumonia Septicemia Suggested Interventions for High Outliers (if at or above 80 th percentile) Could indicate coding or billing errors related to DRGs 193 or 194; ensure documentation supports the principal diagnosis Could indicate coding or billing errors related to over-coding DRGs 870, 871, or 872; consider a sample review of cases with a principal diagnosis of 038.9 (unspecified septicemia to ensure the documentation supports the principal diagnosis Suggested Interventions for Low Outliers (if at or below 20 th percentile) Could indicate that there are coding or billing errors related to undercoding DRGs 193 or 194; consider a sample review of DRGs 177, 178, and 189 Could indicate there are coding or billing errors related to under-coding 870, 871, or 872; consider a sample review from other DRGs, such as DRGs 689 and 690 26
Using PEPPER Example of Target Areas Medical DRGs with CC or MCC Stroke intracranial hemorrhage Suggested Interventions for High Outliers (if at or above 80 th percentile) Could indicate that there are coding errors or billing errors related to over-coding Could indicate potential overcoding. A sample of medical records for DRGs 061, 062, 063, 064, 065, 066 should be reviewed to determine if coding errors exist Suggested Interventions for Low Outliers (if at or below 20 th percentile) Could indicate that there are coding or billing errors related to under-coding Could indicate that there are coding or billing errors related to under-coding of DRGs 061, 062, 063, 064, 065, and 066. A sample of medical records for other DRGs, such as DRGs 067, 068, and 069 should be considered to determine if coding errors exist. 27
Office of Inspector General (OIG) FY 2016 Work Plan The responsibility of the OIG Protect the integrity of Health and Human Service (HHS) programs and the well-being of beneficiaries by detecting and preventing fraud, waste, and abuse Outcomes FY 2015 4,112 individuals and entities excluded from participation in Federal health care programs 925 criminal actions against individuals or entities that engaged in crimes against HHS programs 682 civil actions which include false claims and unjustenrichment lawsuits filed in Federal district court Expected recovery for FY 2015 greater that $3 billion Estimated savings for FY 2015 approximately $20.6 billion 28
Office of Inspector General FY 2016, Examples of OIG Focus Inpatient claims for mechanical ventilation (still active) Review of claims with mechanical ventilation of greater than 96 hours; inappropriate billing identified for patients for patients who received less than 96 hours of mechanical ventilation Payments for patients diagnosed with kwashiorkor (still active) Claims that include the diagnosis of kwashiorkor will be reviewed to determine if the documentation supports the diagnosis; OIG previously identified inappropriate payment for claims with kwashiorkor Medicare payments during MS-DRG payment window (new) Review of Medicare payments to acute care hospitals to determine if certain outpatient claims billed to Medicare Part B for services provided during inpatient stays were allowable and in accordance with the IPPS 29
Office of Inspector General The Office of Inspector General encourages hospitals to develop and implement compliance programs to protect the organization from fraud and abuse Hospitals should conduct regular audits to ensure services are appropriately documented and billed Implement an internal data mining process to identify areas of vulnerability 30
POA Indicators Indicators Y N Condition was present on admission 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 will be treated the same as Y by CMS U will be treated the same as N by CMS 31
Present on Admission Definitions Federally defined as present at the time the order for inpatient admission occurs Conditions that develop during an outpatient encounter, including Emergency department Observation Outpatient surgery Are considered to be present on admission Timing of documentation DOES NOT MATTER Physician may document that a diagnosis was present on admission at any time, including discharge summary or postdischarge query 32
Present on Admission Definitions A diagnosis is considered to be present on admission if The condition was diagnosed during the admission, but was clearly present on admission Chronic conditions Cancer The diagnosis was possible, probable, rule out, suspected, differential on admission, and was confirmed at discharge The condition developed during an outpatient encounter, such as emergency room, physician office, outpatient surgery or observation The signs and symptoms of the condition were clearly present on admission and listed later in the record as a diagnosis 33
Quality Initiatives CMS Hospital Quality Programs Inpatient Quality Reporting (IQR) Chart abstracted measures Claims based measures Patient reported measures Facility reported measures Soon to include electronic clinical quality measures Value Based Purchasing (VBP) Chart abstracted measures Claims based measures Patient reported measures Facility reported measures 34
Quality Initiatives CMS Hospital Quality Programs Hospital Readmission Reduction Program (HRRP) Claims based measures Hospital Acquired Conditions (HAC) Claims based measures Facility reported measures 35
Hospital Acquired Conditions (HACs) The Deficit Reduction Act of 2005 required the identification of conditions that are High cost, high volume, or both Result in the assignment of a case to a DRG that has a higher payment when present as a secondary diagnosis Could reasonably have been prevented through the application of evidence-based guidelines. In FY 2015 the Affordable Care Act required the implementation of imposed financial penalties for hospitals performing poorly regarding HACs 36
Hospital Acquired Conditions (HACs) Domain 1 (15%) Accidental puncture or laceration Perioperative pulmonary embolism or DVT Post-op sepsis Iatrogenic pneumothorax Central venous catheter-related blood stream infection Pressure ulcer Stage 3 and 4 (or unstageable) Post-op wound dehiscence Post-op hip fracture Domain 2 (85%) CLABSI (central line associated blood stream infection) CAUTI (catheter associated UTI) Surgical site infections (SSI) for total hysterectomy and colon surgery MRSA infection Clostridium difficile infection 37
Hospital Acquired Conditions (HACs) The responsibility of the CDS Thoroughly review the record to determine if the condition is present on admission Thoroughly review the record to determine if the condition is clinically valid If clarification is needed, query the physician If after review the condition is determined to be hospital acquired, refer the case to the Quality 38
Develop Team Approach Build alliances and work as a team to achieve successful outcomes Patient Access Case Management Revenue Cycle Denials Management Quality Department COMMUNICATE COMMUNICATE COMMUNICATE 39
CDSs and Coders Partner in Success Partner with the HIM Coders to achieve successful outcomes Participate in HIM quarterly meetings to review Coding Clinics and annual coding updates 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 Develop joint education for CDSs and coders 40
Comprehensive and Holistic Approach for Record Reviews Clinical Indicators Diagnosis Diagnosis Clinical Indicators Present on Admission (POA) NO MORE NO LESS 41
Establish a CDI Steering Committee Support from the Leadership Team is essential to the initial and continued success of the CDI Program If the program is new or in the process of being reinvigorated or if the program is established without a CDI Steering Committee, institute and memorialize specific responsibilities for the CDI Steering Committee For new programs, the CDI Steering Committee typically meets every other week and once a month after implementation for the first year and then quarterly Once CDI is operationalized within the organization, this committee may stop meeting: If the CDI Program falters, this committee should be reconvened 42
CDI Steering Committee Members Include key leaders from executive management CEO CFO CMO/VPMA CIO Providers (e.g., Hospitalists, Community Providers, Surgeons) Compliance Officer CDI Internal Executive Leader CDI Director/CDI Program Manager CDI Provider Educators HIM Director Coding Manager Quality Director 43
CDI Steering Committee Responsibilities Responsibilities (primary) include Obtain and maintain medical staff support Create a chain of command to manage uncooperative or recalcitrant providers (e.g. Escalation Policy) Support the CDI Program financially (especially when new or in the process of reinvigoration) Determine key metrics for review at the strategic level Review rate, query rate, response rate, impact (SOI/ROM and Case Mix Index) Provide feedback to the CDI Operational Committee and Providers Ensure there is a strategic communication process in place to share metrics and recognize future challenges Guide corrective action when necessary 44
Establish a CDI Operational Committee This committee is responsible for the day-to-day operations, management and support for the CDI program Meets weekly (if new or in the process of reinvigoration) and then monthly or quarterly Committee members may include CDI Internal Executive Leader CDI Director/CDI Program Manager (if different from above) CDI Provider Educator Compliance Officer Directors of HIM, Quality and Case Management Clinical Documentation Specialist(s) Coding Supervisor or Coding professionals (dependent on size) Data Analyst 45
CDI Operational Committee Responsibilities Responsibilities (primary) include Hire and train staff Oversee provider and ancillary clinical staff training Implement and manage day-to-day activities (querying, record review, one-on-one provider training) Review program data for tracking and trending Supervise the design of auditing clinical documentation functions Supervise the design of follow-up provider training Disseminate key metrics to the CDI Steering Committee 46
Physician Champion Key to CDI A Physician Champion/Liaison is paramount to the success of a CDI program The Physician Champion should be well known and highly respected by the medical staff Other attributes of an ideal Physician Champion include Practice experience in the community Generalist FP/IM Utilization background/experience Past Chief of Medical Staff or Medical Service History of good documentation practices Proactive for hospital policy implementation Non confrontational 47
Physician Champion Responsibilities include Liaise with CDI staff Interacts with the medical staff Attends Kick off and implementation meeting for CDI (if new or reinvigoration) Attends Medical Executive Committee meetings Attends meetings of the Committee Helps review and/or writes information letters to staff Discusses any problem that arises with the documentation process with regard to physician acceptance Advocates for the providers continued high-quality documentation 48
TEAR DOWN THE SILOS AND WORK AS A TEAM 49
THANK YOU...QUESTIONS? Joni Dion, RHIA, CDIP, CCDS, CPC, CRC AHIMA Approved ICD-10-CM/PCS Trainer jdion@thinkbrg.com (614) 256-2341 Bonnie Peters, CCDS, CDIP, CCS-P, CPC, CRC, COC, CPC-I AHIMA Approved ICD-10-CM/PCS Trainer bpeters@thinkbrg.com (505) 918-7551 50
References APR-DRGs in the Medicaid Population, Judy Sturgeon, CCS, CCDS, For the Record, Vol. 25, No. 5, Pg. 6 http://www.fortherecordmag.com/archives/0313p6.shtml The Evolution of DRGs (Updated), American Health Information Management Association, Journal of AHIMA, April 2010 http://library.ahima.org/xpedio/groups/public/documents/ahima/ bok1_047260.hcsp?ddocname=bok1_047260 Overview of the 3M All Patient Refined (APR) DRGS http://multimedia.3m.com/mws/media/910941o/ebook- overview-of-the-3m-apr-drgs-10-13.pdf?fn=3m_apr_drg_ebook.pdf
References PEPPER Short-term Acute Care Program for Evaluating Payment Patterns Electronic Report, User s Guide Nineteenth Edition https://www.pepperresources.org/ Office of Inspector General Work Plan Fiscal Year 2016 http://oig.hhs.gov/reports-andpublications/archives/workplan/2016/oig-work-plan-2016.pdf