2/1/2016
Clinical Documentation: The Key to Unlocking Your VBP Opportunity
Today’s Speakers Bill Hannah, Principal DHG Healthcare
Wayne Little, Partner DHG Healthcare
Michelle Wieczorek RN RHIT CPHQ, Senior Manager DHG Healthcare
February 2, 2016
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Goals and Objectives • At the conclusion of today’s webinar, the participant will: – Understand the importance of having a robust clinical documentation program – Be introduced to the mandatory government programs impacting payment reform – Understand and articulate the importance of clinical documentation in VBP and other risk‐adjusted alternative Payment Models – Define and understand Key Process Considerations for CDI programs built for success under alternative payment models.
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The Importance of a Robust Clinical Documentation Program Bill Hannah, Principal 4
“Expanded” focus on Clinical Documentation • Coordination of Care • Continuity of Care • Complete Patient Story
Clinical Care
• Foundation for Compliant Coding • Consumption of Resources • Risk Adjustment in both MS and APR DRG’s
Reimbursement Statutory/Regulatory
• Required for Licensure • Accreditation • Third party reviews • Disease Tracking • Comparative Data Used for Quality Improvement
Research
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CMS Accelerates the Timeline for Payment Tied to Quality and Value Metrics “…HHS goal of 30 percent traditional FFS Medicare payment through alternative payment models by the end of 2016… 50 percent by the end of 2018” HHS Press Office 1‐26‐15
100 90 80 70 60 50 40 30
85% of payment tied to quality and value metrics (ex. Hospital Value Based Purchasing, Hospital Readmission Reduction Program)
20 10 0 2011
2015 Traditional, Fee for Service
2016
2018
Alternative Payment Models
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Mandatory Elements – Reform Timeline
January 2016, hospitals and physicians are affecting performance criteria that will impact payments for 2017, 2017, 2018 and beyond
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Clinical Documentation and Risk-Adjusted Alternative Payment Models Wayne Little, Partner 8
Key Considerations • CMS uses a different DRG grouper for payment (MS‐DRG) than for alternative payment programs such as HVBP and Readmissions. • Many legacy CDI Programs are focused upon capturing of secondary diagnoses that impact the MS‐DRG only. • There are many secondary diagnoses that are not classified as comorbid conditions or complications for purposes of the MS‐ DRG assignment – however, they may still have a significant impact on risk adjustment for the alternative payment programs. • Many of these secondary diagnosis may go un‐coded even if documented if they do not impact the MS‐DRG based upon coding norms. 9
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Risk-Adjustment Attribute
MS‐DRG Maintained by 3M
3MTMAPR‐DRG’s Maintained by 3M and NACHRI
Intended Population
Medicare (age 65+ or under age 65 with disability)
All patient refined (based upon the Nationwide Inpatient Sample)
Approach to Severity
Secondary Diagnoses include Complications and Comorbid Conditions applied to some base DRG’s to tier them into with or without CC or MCC designations.
Base DRG’s each have 4 severity levels. No CC or MCC list. Instead, severity depends on both the number and the interrelationship of the secondary diagnoses.
Number of DRG’s
746
1,256
Newborn DRGs
7 DRG’s; no use of birthweight
28 base DRG’s each with 4 levels of severity (total of 112)
February 2, 2016
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Importance of Diagnosis Coding Depth Category Amputation Status, Lower Limb Congestive Heart Failure COPD
Diabetes Major Depressive Disorders Schizophrenia Vascular Diseases
History of CABG
Diagnosis Status amputation, toes, foot, ankle below/above knee CHF Pulmonary Heart Disease COPD Emphysema Chronic Bronchitis Diabetes, uncontrolled Major Depression Schizophrenia Peripheral Vascular Disease Aortic Atherosclerosis Aortic Aneurysm Abdominal Aoristic Aneurysm Presence of coronary bypass graft
ICD‐10 Code Z89.411‐619 I50.9 I27.9 J44.9 J43.9 J42 E11.65 F32.9 F20.9 I73.9 I70.0 I71.9 I73.9 Z95.1
Diagnosis Having the Greatest Impact in Risk Adjusted Reimbursement Programs (Mortality and Readmissions) That Are NOT a CC or MCC Under MS‐DRG System February 2, 2016
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Diagnosis Coding & Trends
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CDI Example Patient with dysuria, fever and altered mental status: • “Urosepsis” documented in progress notes. • Lab reports showed serum creatinine and BUN levels of 4.5 & 50, respectively. Low urinary output. • Physician ordered 1L of IV NS wide open with maintenance IV fluids of 150 cc/hr to follow. • Serial creatinine and BUN levels declined over the next 3 days to 1.2 & 2.4, respectively. • Patient maintained on Symbicort and Lipitor at home. 13
Legacy CDI Program After
Before
MS‐DRG
690 KIDNEY & URINARY TRACT INFECTIONS W/O MCC
MS‐DRG
871 SEPTICEMIA OR SEVERE SEPSIS W MV 96+ HOURS With MCC
Relative Weight
.7823
Relative Weight
1.7934
PDX
Urinary Tract Infection
PDX
Sepsis
SDX
Coronary Artery Dx
SDX
Coronary Artery Dx
APR‐DRG
463
APR‐DRG
720
APR Weight
.5768
APR Weight
.8206
SOI Level
2
SOI Level
2
Risk of Mortality
2
Risk of Mortality
2
Expected Mortality
.3%
Expected Mortality
3.1%
• The CDI Specialist queried the physician based upon lab values and presence of SIRS Criteria to verify an alternate principal dx. of Sepsis, achieving an improved DRG and Reimbursement. 14
Future State CDI Program After
Before
• • •
MS‐DRG
690 KIDNEY & URINARY TRACT INFECTIONS W/O MCC
MS‐DRG
871 SEPTICEMIA OR SEVERE SEPSIS W MV 96+ HOURS With MCC
Relative Weight
.7823
Relative Weight
1.7934
PDX
Urinary Tract Infection
PDX
Sepsis
SDX SDX
Coronary Artery Dx
Acute Renal Failure with ATN COPD
APR‐DRG
463
APR‐DRG
720
APR Weight
.5768
APR Weight
3.0141
SOI Level
2
SOI Level
4
Risk of Mortality
2
Risk of Mortality
3
Expected Mortality
.3%
Expected Mortality
6.3%
The CDI Specialist sought clarity in the presence of COPD – a secondary diagnosis not impacting the MS‐DRG through reviewing of the medication list and noting Symbicort. The CDI Specialist also noted the presence of clinical indicators indicative of ATN; and queried the physician to clarify the diagnosis. The combination of the additional secondary diagnosis moved the SOI, ROM and Expected Mortality. 15
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Key Performance Considerations and The Future State Requirements of CDI Programs Michelle Wieczorek, Senior Manager 16
Impacts to Legacy CDI Programs Preparing for Future State Requirements Data Analytics
Collaboration
Operations
Technology
Workflow
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Data Management and Analytic Considerations MS‐DRG based metrics are no longer sufficient for measuring the impact of the CDI Program on the documentation and coding processes. As a result, different metric dashboards and reports are required.
An APR‐DRG and an MS‐DRG is stored on all patients upon each review. (DRG Progression) Acuity Measures for SOI and ROM are stored on all patients upon each review. Reporting solution accommodates Provider, Patient and Population Centric data.
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Sample Key Process Indicator: Coding Depth Secondary Diagnosis Capture Per IP Case
15.5 15.4 15.3 15.2 15.1 15 14.9 14.8 14.7 14.6 14.5 14.4 14.3 14.2 14.1 14 13.9 13.8 13.7 13.6 13.5 13.4 13.3 13.2 13.1 2012
Q1
2013 Q2
Q3
2014 Linear (Q4)
Q4
2015
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Sample Key Process Indicator: Severity of Illness Distribution Severity of Illness Distribution for Inpatient Admissions 100% 95% 90% 85% 80% 75% 70% 65% 60% 55% 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Q1
Q2
Q3
Q4
Q1
Q2
2013
Q3
Q4
2014 SOI 1
SOI 2
SOI 3
Q1
Q2
Q3
Q4
2015 SOI 4 20
Technology Considerations Because the CDI Specialist is doing more reviews, assessing for severity and APR‐DRG impacts, and consequently creating more queries for the provider, the technology considerations for the CDI program are heightened. APR‐DRG Grouper is Licensed for use by CDI Specialists and Coders Software Solution Supports CDI Workflow Structured Data from CDI Solution Available for Reporting New Reporting Metrics
Electronic Query Solution for Providers‐Integrated with EHR
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Sample: Impact of Electronic Query Response Tool
Percent
Query Response Rate within 24 Hours Cardiology 100 95 90 85 80 75 70 65 60 55 50 45 40 35 30 25 20 15 10 5 0
Query Response Tool Implemented
Q1
Q2
Q3
Q4
Q1
Q2
2014 Dr. A
Dr. B
Q3
Q4
2015 Dr. C
Dr. D
Dr. E
Dr. F
Dr. G
GOAL 22
Workflow Considerations CDI Workflow must be adapted to accommodate deeper severity‐based reviews, more coaching with providers, and prioritization of cases for initial, subsequent and reconciliation reviews. The CDI Specialist has access to an encoder and a Working DRG (MS‐DRG and APR‐DRG) is assigned as part of CDI Workflow Concurrent Workflow includes Verbal Queries and Face Time with Providers Workflow is driven by worklists to aid in prioritization The Working DRG is Concurrently Available to Care Management and Quality
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Operational Considerations Transforming the CDI Function from a legacy or MS‐DRG focused program to a future state acuity and quality outcome program requires several operational considerations for training and staffing. The Workforce is trained and knowledgeable in Risk Adjustment There is a DRG Reconciliation Process for all DRG Mismatches CDI Peer Physician Advisor Roles are Implemented
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Collaboration Compelling providers to improve clinical documentation can no longer be accomplished without an ongoing, systematic process which includes hospital departments combining their data and skills to support their providers. There are regularly occurring opportunities to share Provider, Patient and Population Centric reports with the Medical Staff The CDI Program and Coding Program utilize the same standard query tools There is a regularly occurring opportunity to share CDI program information with Coding, Revenue Cycle, Care Management, and Finance 25
Recommended Next Steps • Think about your organizational preparedness for alternative payment methods. – Is your organization ready for managing your revenue at risk?
• Think about how well your CDI Program is prepared for meeting the challenges of payment reform. – Review the CDI Program Checklist which will be emailed to you in follow up to today’s presentation.
Contact Information
Bill Hannah, Principal DHG Healthcare Atlanta, Georgia P: 404.575.8921
Wayne Little, Partner DHG Healthcare Atlanta, Georgia P: 404.681.8297
Michelle Wieczorek, Sr. Manager DHG Healthcare Atlanta, Georgia P: 814.440.0471
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