Using the Inpatient Psychiatric Facility (IPF) PEPPER to Support Auditing and Monitoring Efforts: Session 1 March, 2016 Kimberly Hrehor
Agenda Session 1: History and basics of PEPPER IPF PEPPER target areas Percents and percentiles Comparison groups Session 2: PEPPER Demonstration Session 3: How to use and obtain PEPPER Helpful resources 2
Objective: To help you understand PEPPER so that you can use this tool, provided at no cost by the Centers for Medicare & Medicaid Services (CMS), to support auditing and monitoring efforts with the goal of ensuring compliance with Medicare regulations and preventing improper Medicare payments. 3
What is PEPPER? Program for Evaluating Payment Patterns Electronic Report (PEPPER) summarizes Medicare claims data statistics for one IPF in areas ( target areas ) that may be at risk for improper Medicare payments. PEPPER compares an IPF s Medicare claims data statistics with aggregate Medicare data for the nation, MAC jurisdiction and state. PEPPER cannot identify improper Medicare payments! 4
History of PEPPER PEPPER was originally developed in 2003 for short-term acute care PPS hospitals. PEPPER is also available for long-term (LT) acute care PPS hospitals, critical access hospitals (CAHs), inpatient psychiatric facilities (IPFs), inpatient rehabilitation facilities (IRFs), partial hospitalization programs (PHPs), hospices, skilled nursing facilities (SNFs) and home health agencies (HHAs). 5
Why are IPFs Receiving PEPPER? CMS is tasked with protecting the Medicare Trust Fund from fraud, waste and abuse. The provision of PEPPER supports CMS program integrity activities. PEPPER is an educational tool that is intended to help providers assess their risk for improper Medicare payments. 6
PEPPER Summarizes Medicare Data Paid inpatient Medicare claims Inpatient psychiatric facility or distinct part unit Claim facility type = hospital Inpatient part A claim Claim has a valid medical record number Medicare claim payment amount > $0 (Medicare Secondary Payer claims are included) Final action claim Exclude HMO claims Exclude canceled claims 7
PEPPER Data Organized in three 12-month time periods based on federal fiscal year (FY). FY 2013 FY 2014 FY 2015 Q4FY15 release contains statistics for discharges at the IPF that end between Oct. 1, 2012 through Sept. 30, 2015 (fiscal years 2013, 2014 and 2015). 8
PEPPER Data Restriction Due to CMS data restrictions, the PEPPER will not display statistics when the numerator or denominator count is less than 11 for a target area in any time period. Some providers may not see any data for some target areas or time periods. Some providers will not have a PEPPER available. 9
IPF Improper Payment Risks PEPPER does not identify improper payments. IPFs are reimbursed through the IPF prospective payment system (PPS). IPFs can be at risk for improper Medicare payments due to coding errors or unnecessary admissions. IPF PEPPER target areas were identified based on a review of the IPF PPS, coordination with CMS IPF subject matter experts and analysis of national claims data. 10
Target Area Area identified as potentially at risk for improper payments Focused on admission necessity or coding issues Constructed as a ratio: Numerator = discharges identified as potentially problematic (likely to be miscoded or admitted unnecessarily) Denominator = larger reference group that contains the numerator 11
IPF PEPPER Target Areas Target Area Comorbidities *revised in Q4FY15 release No Secondary Diagnoses *new in Q4FY15 release Outlier Payments Target Area Definition N: count of discharges with at least one comorbidity on the claim D: count of all discharges N: count of discharges with no secondary diagnosis codes D: count of all discharges N: count of discharges with an outlier approved amount greater than $0 D: count of all discharges 12
IPF PEPPER Target Areas, 2 Target Area 3- to 5-Day Readmissions 30-Day Readmissions *revised in Q4FY15 release Target Area Definition N: count of index (first) admissions for which a readmission occurred within 3 to 5 calendar days (4 to 6 consecutive days) to the same IPF or to another IPF for the same beneficiary D: count of all discharges excluding patient discharge status code 20 (expired) N: count of index (first) admissions for which a readmission occurred within 30 days to the same IPF or to another IPF for the same beneficiary (identified using the Health Insurance Claim number), excluding patient discharge status codes 65 (discharged/transferred to an IPF), 93 (discharged/transferred to an IPF with planned acute care hospital readmission), 07 (left against medical advice) D: count of all discharges excluding patient discharge status codes 65, 20, 93, 07 13
IPF PEPPER Target Areas, 3 Target Area One-day Stays *new in Q4FY15 release No Ancillary Charges *new in Q4FY15 release Target Area Definition N: count of discharges where the beneficiary was admitted and discharged on the same day or was discharged on the day after admission D: count of all discharges N: count of discharges with no ancillary charges on the claim D: count of all discharges 14
Three Basic Statistics Count of discharges (numerator and denominator) Payments (sum and average) Average length of stay 15
Percents and Percentiles Percents and percentiles are at the heart of PEPPER. It is easy to confuse these terms. The following slides clarify the definitions and how they relate to each other in PEPPER. 16
Target Area Statistics Numerator number of target area discharges; will not display if <11 Denominator number of all denominator discharges; will not display if <11 17
Target Area Percents Target area percents are calculated by dividing the number of target discharges by the number of denominator discharges for each provider for each time period, then multiplying by 100. Example: Comorbidities 18
Percentiles The target area percent lets the IPF know its billing patterns. More useful information comes from knowing how it compares to other IPFs, which is why we calculate percentiles. Definition of a percentile: The percentage of IPFs with a lower target area percent. 19
Percentiles, cont. To calculate percentiles for all IPFs in a comparison group (nation, jurisdiction or state), the target area percents are sorted from largest to smallest for each time period. Example: If 40% of the IPFs target area percents were lower than IPF A, then IPF A would be at the 40 th percentile. 20
Percentile Calculation Example 44% 23% 21% 20% 18% 15% 14% 13% 12% 8% 80 th percentile 20 th percentile The top two IPFs percents are at or above the 80 th percentile. The bottom two IPFs percents are at or below the 20 th percentile. 21
Comparisons in PEPPER PEPPER provides state, MAC jurisdiction and national comparisons. National Comparison MAC Jurisdiction Comparison State Comparison 22
MAC Jurisdictions 23
Review: How does PEPPER identify Providers at Risk? A provider s target area percent is compared to other providers percents in the nation, MAC jurisdiction and state. If the provider s target area percent is at/above the national 80 th percentile or at/below the national 20 th percentile, it is identified as at risk for improper Medicare payments. Compare and Target Area reports: Red bold print at or above the national 80 th percentile for the target area. Green italic print at or below the national 20 th percentile for the target area (areas at risk for undercoding only). 24
Top DRG Report Lists the top DRGs for the IPF by number of discharges that end in the most recent fiscal year. Includes number of discharges for the DRG, the proportion of discharges for the DRG to total discharges, and the ALOS for the DRG. Supplemental report; has no impact on outlier status or risk for improper payments. 25
Jurisdiction Top DRG Report Lists the top DRGs by number of discharges in the most recent fiscal year for all IPFs in the MAC jurisdiction. Include same data elements as the IPFspecific report, as well as the jurisdiction and national ALOS for the top DRGs. 26
Session 2: IPF PEPPER Demonstration March, 2016 Kimberly Hrehor
Session 3: How to Use and Obtain IPF PEPPER and Helpful Resources March, 2016 Kimberly Hrehor
Review How does PEPPER identify Potential Risk? A provider s target area percent is compared to other IPFs percents in the nation, MAC jurisdiction and state. If the IPF s target area percent is at/above the national 80 th percentile or at/below the national 20 th percentile, it is identified as at risk for improper Medicare payments. Compare and Target Area reports: Red bold print at or above the national 80 th percentile for the target area. Green italic print at or below the national 20 th percentile for the target area (areas at risk for undercoding only). 29
How to Prioritize PEPPER Findings Use the Compare Targets Report. Consider outlier status compared to: 1. Nation 2. Jurisdiction 3. State Consider Number of Target Discharges and Sum of Payments. Refer to the target area reports for specifics, changes over time. Use Top DRGs report to supplement analysis. 30
IPF PEPPER User s Guide Documentation of claims eligible for inclusion Target area numerator and denominator definitions Guidance on how to use PEPPER and how to interpret PEPPER findings Available at PEPPERresources.org in the Inpatient Psychiatric Facilities section 31
Using PEPPER Coding data source for DRG validation audits Consider selecting cases to review from the numerator for high outliers. You may wish to further target records for review (e.g., by length of stay). Share findings internally with coders; use as springboard for discussion and education. 32
Using PEPPER, 2 Compliance can guide audits for outlier areas Audit results used to develop specific action plans for ensuring compliant documentation, providing education regarding admission necessity and improving coding accuracy. 33
Using PEPPER Utilization review/quality Consider selecting cases for review from the numerator. You may wish to further target records for review (e.g., readmissions). 34
Using PEPPER, 3 Preparation for Recovery Auditors Support of auditing, monitoring and benchmarking activities 35
National-level Data National-level data for the target areas (number of discharges for the numerator/denominator, average length of stay, total payments) is available at PEPPERresources.org on the Data page and updated following each release. Available for all IPFs, free-standing IPFs and IPF distinct part units. 36
National-level Data Reports Program for Evaluating Payment
How is IPF PEPPER distributed? Electronically via QualityNet (QN) to QN administrators and those with basic QN accounts and the PEPPER recipient role. If there is no QualityNet administrator at your IPF, or if your IPF s QualityNet administrator needs assistance, contact the QualityNet Help Desk at www.qualitynet.org PEPPER cannot be sent via e-mail. IPF PEPPER will be distributed annually. 38
How Can I Receive PEPPER? Work with your hospital s QualityNet administrator to obtain a basic user account. Ask for PEPPER recipient and File Exchange and Search roles. 39
Now what? Refer to the user s guides. Share internally. Guide auditing and monitoring. Look for increases or decreases, identify root causes. Review medical records. Be proactive and preventive. 40
Strategies to Consider. Do Not Panic! Indication of high outlier does not necessarily mean that compliance issues exist. But: Determine Why You are an Outlier Sample claims using same inclusion criteria. Review documentation in medical record. Review claim; was it coded and billed appropriately based upon documentation in medical record? Ensure following best practices, even if not an outlier. 44
Who has Access to PEPPER? PEPPER is only available to the individual provider. PEPPER is not publicly available, cannot be released to consultants, etc. TMF does not send PEPPERs to MACs/Recovery Auditors, but does provide them with an Access database that contains the PEPPER statistics for providers in their jurisdiction/region. 42
For assistance with PEPPER: Visit PEPPERresources.org for the PEPPER User s Guide and training materials. If you are in need of individual assistance, click on Help/Contact Us, and submit your request through the Help Desk. Complete the form, and a TMF staff member will respond promptly to assist you. Please do not contact your QIO or any other organization/association for assistance with PEPPER. 43
Pepper Resources website Program for Evaluating Payment 44
Feedback on PEPPER We are interested in your comments and suggestions! 45
Together we can make a difference 46