1 The Postacute Care Setting: Integrating CDI Into Multiple Outpatient Settings Beth Wolf, MD, CCDS, CPC Medical Director, Health Information Management Roper St. Francis, Charleston, SC Kathryn DeVault, MSL, RHIA, CCS, CCS P, FAHIMA Manager, HIM Consulting UASI, Cincinnati, OH Learning Objectives At the completion of this educational activity, the learner will be able to: Identify postacute care settings where clinical documentation integrity can offer the biggest impact Discuss the unique documentation, coding, and billing requirements for several postacute areas Explain how CDI can be integrated into postacute care 2 CDI in the Postacute Setting Need for documentation accuracy and integrity across healthcare settings Quality documentation does impact transitional settings including independent practices and private providers CDI program structure will differ from the acute inpatient setting Staffing challenges due to volume of OP cases Issues related to timing concurrent review may not be possible Organizational support senior leadership and providers 3 1
4 Postacute Care CDI Impact Reduce incomplete and insufficient documentation Specificity for HCC assignment and RAF scores Complexity of care and E/M selection Procedure coding accuracy and completeness Clinical validation Ambulatory Payment Classification (APC) OPPS Reduce incorrect translation to codes Provider awareness of code selection and impact Professional coder interaction with clinicians Ensure medical necessity addressed Prevent denials and delays in care Improve clinician and patient satisfaction Reduce billing errors Postacute Care CDI 5 CDI Postacute Care Settings Long term acute care hospital (LTCH) Inpatient rehab (IRF) Skilled nursing facility (SNF) Home based services Hospice Home healthcare Ambulatory settings Wound care clinic Transitional care management (TCM) services 6 2
7 Long Term Acute Care Hospital (LTCH) Improving Medicare Post Acute Care Transformation Act (IMPACT) LTCH Assessment Tool Long Term Care Hospital Continuity Assessment Record and Evaluation (LTCH CARE) Data Set Payment under MS LTC DRG prospective payment system (PPS) Follows the Uniform Hospital Discharge Data Set rules Integrates CDI similarly to acute care Documentation of all medical conditions/diagnoses Long length of stay (LOS) with multiple secondary diagnoses Concurrent query opportunity Inpatient Rehabilitation Facility (IRF) Improving Medicare Post Acute Care Transformation Act (IMPACT) IRF Assessment Tool Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF PAI) Medical necessity Patient requires intensive medical management Physician oversight, monitoring, and treatment at least 3 times per week Patient requires daily skilled nursing services Patient requires, tolerates, and participates in a multidisciplinary program by at least two disciplines (PT, OT, ST) Patient is able to actively participate in rehabilitation 8 Inpatient Rehabilitation Facility (IRF) Clinical documentation integrity Pre admission screening Needs to stand alone and justify admission Physician documentation Provides justification for admission Nursing documentation Rehab nursing plan of care links the conditions diagnosed by the physician and the rehab goals set by therapy Therapy documentation Rehab therapy plan of care links the functional deficits to the medical conditions and includes progress & barriers 9 3
10 Inpatient Rehabilitation Facility (IRF) Documentation requirements: Evaluations and reevaluations Plan of care Therapy goals Certification/recertification Progress reports continuing medical necessity Treatment notes for each treatment day Services must relate directly and specifically to a written treatment plan Must be established by therapist who will be providing the services (PT, OT, ST) Must be signed and dated and include professional identification Inpatient Rehabilitation Facility (IRF) Common physician documentation needs CVAs type (hemorrhage, infarction), location, cause (thrombosis, embolism, occlusion, stenosis), site (cerebral arteries, precerebral arteries), laterality (dominant, nondominant) Amputations date, location, laterality, reason Fractures cause (stress, trauma, pathologic), how it occurred, laterality and location, type (open/closed, displaced/nondisplaced), encounter (initial, subsequent, sequela) Trauma (brain, spinal cord, major multiple trauma) when? low? location, level of SCI, type of paralysis, laterality, loss of consciousness and duration, impairments or deficits 11 Skilled Nursing Facility (SNF) Improving Medicare Post Acute Care Transformation Act (IMPACT) SNF Assessment Tool Minimum Data Set (MDS) 3.0 Documentation requirements: Certification/recertification Therapy documentation Treatment plan Progress notes Therapy minute logs Orders/progress notes to support MDS RUG billing Diagnosis coding Diagnoses and sequencing dependent on circumstance of admission or continued stay Erroneous diagnosis coding may result in rejected claims 12 4
13 Home Health Improving Medicare Post Acute Care Transformation Act (IMPACT) Assessment Tool Outcome and Assessment Information Set (OASIS) Documentation requirements Focus on patient s conditions and expected therapy needs Risks: Homebound documentation Altering documentation to obtain higher reimbursement Documenting/billing for visits not made Billing Medicare for patients that don t require the skills of a nurse or therapist Home Health Documentation for home health patients: Provides proof for: Coverage Reimbursement Quality Reflects care provided to specific patient Reflects standard of care provided Provides information for data collection and benchmarking Protects organizations from alleged practice/fraud complaints 14 Home Health Documentation for home health patients (cont.): Source document for communication and care coordination Chronicles care from admission to discharge Describes patient s clinical status and ongoing needs Supports quality of care 15 5
16 Hospice Eligibility and local coverage determinations (LCD) The LCDs for the hospice s geographic area are used as guidelines to help a physician determine hospice eligibility The LCDs are not regulations and should not be used exclusively to determine or provide evidence of hospice eligibility Certification or recertification is based upon a physician s clinical judgment, and is not an exact science Congress made this clear in Section 322 of the Benefits Improvement and Protection Act of 2000 (BIPA), which says that the hospice certification of terminal illness shall be based on the physician s or medical director s clinical judgment regarding the normal course of the individual s illness Hospice Improving Medicare Post Acute Care Transformation Act (IMPACT) Hospice Requirements (FY 2017 update) Required survey every 3 years Review of patients > 180 days in care Increased payment for the first 60 days Required to report all diagnoses Top diagnoses FY 2015 Alzheimer s disease Congestive failure, unspecified Lung cancer COPD Senile degeneration of the brain Parkinson s disease Heart disease, unspecified CVA/stroke 17 Ambulatory Settings Wound care clinics Infusion centers Diagnostics/imaging Ambulatory surgery Physician clinics Primary care Specialty care 18 6
19 Wound Care Clinic Key information for documentation: Each encounter should stand alone Type of wound pressure, chronic, nonhealing, diabetic Location including laterality Depth of wound Stage of pressure ulcer Depth of non pressure ulcer Breakdown of skin Exposure of fat layer Necrosis of muscle Necrosis of bone Wound Care Clinic Inappropriate use of modifier 25 (E/M) Use of hyperbaric oxygen when all other wound management modalities have failed, not accompanied by physician order for the procedure Lack of or poorly documented wound dimensions Confusing debridement documentation Coding multiple layers of debridement per site instead of coding the deepest layer for debridement Coding dressing of wounds separate from E/M service 20 Medical Necessity LCDs, NCDs Infusion centers Documentation needs: Signed, dated, and timed orders Type, route, site, and start/stop time Consistent documentation between physician and nursing Diagnostics (e.g., cardiac cath) Ambulatory/outpatient surgery Pacemaker, AICD 21 7
22 Transitional Care Management Services Transitional care management (TCM) services are for patients transitioning from an inpatient hospital setting (including acute hospital, rehab, long term acute care, observation status, and skilled nursing) to a community home setting. TCM improves care coordination after discharge and subsequently cuts down on readmissions. TCM should NOT be reported on every patient that has follow up after a hospital discharge. These codes were developed as a means to reimburse providers for the significant extra work involved with a complex, multidisciplinary patient. Transitional Care Management Requirements 1. An interactive contact or face to face visit within 2 business days after discharge Documentation must show that it is more than just a call to schedule a follow up appointment Reason for continued care Discussion of hospital stay, to include medication reconciliation 2. Face to face visit 3. Medical decision making of moderate or high complexity 99495 Face to face visit within 14 calendar days of discharge and medical decision making of at least moderate complexity during the service period 99496 Face to face visit within 7 calendar days of discharge and medical decision making of at least high complexity during the service period 23 HCCs and Risk Adjustment 24 8
25 Evaluation and Management Payment: Fee for Service (FFS) vs. Risk FFS Physician paid no matter what the quality or outcome Paid more for doing more Documentation of a diagnosis used to loosely match a procedure no specificity required Risk Payment based on diagnoses that reflect intensity of care and risk for events Higher specificity in documentation often reflects better defined health (and financial) risk Only pay for conditions being currently managed Defining Risk With Hierarchical Condition Categories (HCCs) HCC diagnoses add up to a Risk Adjustment Factor (RAF), which Medicare Advantage uses to pay clinicians Implemented in 2004 Used to adjust Medicare capitation payments to Medicare Advantage healthcare plans predict cost in the next year 8,800 ICD 10 codes map to 79 HCCs The weight of the diagnoses can change annually based on outcomes Accuracy DEPENDS on submission of all relevant diagnoses, which are cumulative 26 CDI Specialist Additive Benefits Identify opportunity for documentation specificity Translate at point of care the implications of documentation Reinforce compliant documentation of true health status Clinical validation, cloned notes, mismatched information Create tools to improve point of care documentation Electronic prompts for medical necessity and HCC capture Support the success of postacute care services Risk adjusted outcomes Alternative Payment Models Bundled payment models, Medicare Advantage, ACOs 27 9
28 Integrating CDI Into Postacute Care Do your homework Know your system services Know your system priorities Identify current areas of concern Meet with: Compliance, quality, transitional care teams Service line directors, department chairs, CMO/CFO Outpatient physician services Ask about: High amount of denials, ongoing documentation issues CMS/payer regulations Underperforming postacute care areas Postacute Care CDI Metrics Quality metrics Case management Reduce inappropriate admissions Concurrent capture of missing procedures Reduced bill hold times due to missing documentation or missing charges Increased risk adjustment scores based on capture of HCC weighted diagnosis codes Reduce denials Medical necessity specificity Physician engagement 29 Common Mistakes Delaying implementation of a CDI program Trusting clinicians (or software) to code correctly Overlooking the need to audit documentation and coding regularly Coding diseases and conditions without supporting documentation Failing to keep references and resources current Believing education is complete Not obtaining stakeholder support Creating processes without identifying owners and outcomes 30 10
31 Useful References Data Elements and Tools Used in Measure Development (example of pressure ulcer in postacute care transitions) https://www.cms.gov/outreach and Education/Outreach/NPC/Downloads/2016 10 13 ppt measures dataelements.pdf Long Term Acute Care Hospital LTCH CARE Data Set & LTCH Quality Reporting Program Manual https://www.cms.gov/medicare/quality Initiatives Patient Assessment Instruments/LTCH Quality Reporting/LTCH CARE Data Set and LTCH QRP Manual.html Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF PAI) Updated Training Manual https://www.cms.gov/medicare/medicare fee for servicepayment/inpatientrehabfacpps/irfpai.html Useful References Skilled Nursing Facility Quality Reporting Program (SNF QRP) https://www.cms.gov/medicare/quality Initiatives Patient Assessment Instruments/NursingHomeQualityInits/Skilled Nursing Facility Quality Reporting Program/SNF Quality Reporting Program Measures and Technical Information.html Home Health Quality Initiatives https://www.cms.gov/medicare/quality Initiatives Patient Assessment Instruments/HomeHealthQualityInits/index.html?redirect=/homehealth qualityinits/ Hospice Quality Reporting Requirements https://www.cms.gov/medicare/quality Initiatives Patient Assessment Instruments/Hospice Quality Reporting/ Transitional Care Management Services https://www.cms.gov/outreach and Education/Medicare Learning Network MLN/MLNProducts/MLN Publications Items/ICN908628.html 32 Thank you. Questions? bawolfy@yahoo.com kathy.devault@uasisolutions.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. 33 11