ENGAGING PHYSICIANS FOR IMPROVED OUTCOMES: CLINICAL DOCUMENTATION, FINANCIAL & PATIENT CARE Northeast Ohio HFMA GHALI May 20, 2016 James Begley, MD, MS Physician Champion, ICD-10 & Medical Records Committee Chairman Christina Janus, MBA, RHIA, CHAM Associate Director, Health Information Management The following report is proprietary information and constitutes trade secrets of The MetroHealth System and may not be disclosed in whole or part to any external parties without the express consent of The MetroHealth System. This document is intended to be used internally for MetroHealth System discussion.
Today s Objectives Discuss how clinicians, revenue cycle and information technology have collaborated to improve workflow and clinical documentation for a successful life after ICD-10 Outline the importance of maintaining higher levels of clinical documentation specificity & accuracy for improved value and to mitigate risks Explore best practices on how the use of revenue cycle metrics, clinical data, and ongoing education to improve productivity, financial performance and clinical outcomes
Finally!!
We ve spent nearly 5 years preparing. Committees, Meetings, Sub- Groups Training & Education Implementing New Clinical Documentation Requirements Remediating Systems & Applications Modifying Reports & Data Extracts Payer Testing & Dual Coding Performing Financial & Data Analytics Remediating Workflow & Processes Go Live & Post Go Live Plans
First 8 Months in Review Overall smooth transition so far Claims traffic moving with little congestion CMS and other large payers indicate calls and rejections have been lower than expected Industry literature states initial decrease in coder productivity ranging from a 5%-35% drop A few toe-stubbing issues with CMS LCDs (local coverage determination) and internal systems Impacted professionals, i.e., Revenue Cycle, Clinicians, Decision Support/Research, etc. are experiencing a learning curve as expected, but growing more accustomed to the new code set and documentation requirements
Moving Forward Ongoing coding and clinical documentation reviews, education and training are a part of the normal course of business Key benchmark metrics / KPIs (key performance indicators) for monitoring progress should be established and monitored against baseline to detect problems and identify opportunities for improvement ICD code set is updated every October 1 st expect many code updates for FY 2017: For ICD-10-PCS (inpatient procedures) 3,651 new codes proposed and 487 revised code titles. Of the proposed 3,651 new codes, 3,549 are cardiovascular system codes. Approximately 1,900 new diagnosis codes are proposed, 313 deleted codes, and 351 revised codes included
Assessing ICD-10 Progress Key Performance Indicators Days to Final Bill Coder Productivity Use of ICD-10 Codes on Prior Authorizations & Referals Days to Payment Claims Acceptance / Rejection Rates Volume of Coder Questions Request for Additional Information Incomplete or Missing Charges Incomplete or Missing Diagnosis Codes Claims Denial Rate Daily Charges / Claims Use of Unspecified Codes Payment Amounts Clearninghouse Edits Return to Provider / Fiscal Intermediary Shared System Volumes Reimbursement Rates Payer Edits Medical Necessity Pass Rates Source 2016 CMS ICD-10 cms.gov/icd10
Cheers to success!
ICD-11 Just in case you are wondering WHO (World Health Organization) authors this international code set Currently in Beta Phase and is not a functional tool yet Due by 2018 (but this date keeps getting pushed back) Includes only Diagnosis codes as ICD-10-PCS developed for the USA only
HCC (Hierarchical Condition Categories) HCCs Risk adjusted model to help healthcare facilities assess patient health statuses This model uses data to prospectively estimate predicated costs for enrolled members in the ambulatory setting Estimates are based on anticipated risks under the Medicare Advantage capitation payment system Opportunity to improve clinical documentation by utilizing a more accurate method to determine a patient s condition which can help determine best care path for patient based on diagnosis
Medicare Risk Adjustment Case Study (or, what Medicare doesn t know can hurt you) Reality: A 76 year old woman with Type 2 Diabetes Mellitus with Chronic Renal Insufficiency, Paroxysmal Atrial Fibrillation (on warfarin), and Breast Cancer (s/p right mastectomy 15 years ago) presents for a follow up visit. Medicare s view (based on our diagnoses): A 76 year old woman with uncomplicated Diabetes Mellitus presents for a follow up visit.
Keeping Score What the Provider Knows Points What Medicare Knows Points Female patient 0.437 Female patient 0.437 Diabetes with renal disease - HCC 19 Breast cancer - HCC 12 0.154 0.368 Diabetes without complications - HCC 18 0.118 Atrial Fibrillation - HCC 86 0.295 TOTAL 1.254 0.555 Patient is more than twice as complex as Medicare knows
Risk Adjustment Alert in Epic Tools we have implemented at MetroHealth to assist providers with HCC documentation: Will display if Epic detects the presence of conditions (from prior visits or the problem list) which have not yet been billed this calendar year Shows provider a list of these conditions as a reminder to the provider to bill for them if the provider addressed them
Alert
Sidebar Report Same info as shown in the alert All of the HCC s that Epic thinks apply Most recent date each dx was used (no date = on problem list)
How Should Providers Optimize Tool? Bill for all the conditions that you (the provider) address Address medical conditions that need to be addressed Utilize technology to remind and guide through the clinical documentation process
Slicer Dicer Could be Next Cutting-edge Tracking Tool
Slicer Dicer A self-service interactive analytical tool available through the EPIC EMR system designed for medical providers Medical providers can: Parse a large quantity of clinical & population data contained within the system Interact with and refine data Find trends across groups of patients Compare the provider s patients to a larger population Take timing into account Identify specific sets of patients Make new discoveries Show evidence to patients to help change their behavior
Slicer Dicer - Data Available Patient Demographic Information 1. Age 2. Alive/dead 3. Gender 4. Race 5. Ethnicity (coming soon 5/1) Healthcare System Information 1. Provider(s) involved in care 2. Location of care 3. Encounter type Allergies Family History Health Maintenance Immunizations Medication History Data goes back as far as 6/1/1999 (changes over time) Laboratory Information (lab components) Encounter Diagnosis Codes (individual codes and groupers ) Procedures (?reliability validate specific codes you might want to use)
Reporting Tools Table Characteristic Slicer Dicer Explorys Reporting Workbench Report Clarity Report Self-Service Y Y N* N* N Raw Data # of patients 1.1 m 50m** 1.1m 1.1m 1.1m Individual patients N*** N*** Y Y Y Downloadable data N*** N N*** Y Y # of data types medium low medium medium high Effort to create report very low very low Low medium high * Once created can be semi-self-service ** Includes ~49 million patients from other healthcare systems ***With additional security and/or permission individual level data can be obtained
Example: COPD without Pulmonary Function Tests (PFTs) The American Thoracic Society recommends spirometry testing for the diagnosis. Useful to rule out COPD (Chronic Obstructive Pulmonary Disease) which is frequently over-diagnosed Helps prognosticate, educate Is a billable procedure, which we are missing out on.
Questions How many patients with COPD do not have PFTs? How many of those present with exacerbations and do not have PFTs?
Population: Everyone
COPD Exacerbations
How do I factor in PFTs?
Procedures not completed, there must be a better way!
Comparison
What can Providers do with this? Pilot inpatient spirometry to clarify the diagnosis New BPA activated on discharged, linking to PFTs +/- Pulmonary referral
Conclusions Invest in education & training Clinical documentation is paramount, being used for medical coding & reimbursement and is increasingly used to gauge the quality of care provided & public outcomes data Choose effective and focused metrics What truly makes a difference and measures outcomes? Invest in data & information technology Revolution in data availability drives how care is delivered, managed and paid Healthcare transformation requires taking all of this data and turning it into actionable, meaningful information Ensure systems and tools are optimally utilized and are scalable to a quickly changing healthcare industry Focus on collaboration Medical providers, revenue cycle, finance & information technology professionals, executive sponsorship, etc. are all crucial players needed for team success
Questions