Building a Successful Outpatient Clinical...

Building a Successful Outpatient Clinical Documentation Integrity Department

2016 A A PC R EGI ONAL CON FER EN CE – AT LA N TIC C I T YOC TOBER 6 TH 2016

PRESENTERSDonna Beaulieu, CRC, C-CDIS, CPC, CPMA, CPC-I, CEDC, CEMC, CFPC, CRC, CCP-P, CRPHasan Zaidi, MPH, CPC, CRC, CEDC, CSPPM

Presentation Agenda

Shift Towards Fee for Value◦ Overview of new Payment Methodologies

Outpatient Clinical Documentation Integrity (CDI)◦ Purpose

◦ Process

◦ Outcomes

Risk Adjustment Overview◦ Hierarchical Condition Category Codes

◦ Case Studies

Questions/Feedback Session

Change is inevitable.

“In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer

exists.”

—Eric Hoffer, American philosopher and author of The True Believer: Thoughts on the Nature of Mass Movements

Shift Towards Fee for Value: Why?

Outcomes are not always achieved◦ 2000 Institute of Medicine Report, “To Err is Human”

Cost is higher than is sustainable◦ Escalating costs for the last 25 years

Unnecessary Costs◦ 1/3 of what we spend money on in healthcare is unnecessary

◦ Fear of failing to find something

◦ Defensive medicine

◦ Lack of interoperability between EHR

◦ Other reasons

Shift Towards Fee for Value

Increase provider adherence and compliance with evidence based practices

Increase patient adherence and compliance with care plans

Reduce hospitalizations

Reduce length of stay

Avoid unnecessary readmissions

Avoid redundant tests and studies

Improve utilization management for drug therapies and device therapies

Fee for Service Fee for ValueFee for Service Fee for Value

Service is rendered, payment is received by payer

Service is rendered, payment is dependent on:

• Meeting quality measures• Participating in fee for value payment

models• Effective care coordination of

patients via primary care medical home

Quantity drives revenue (high volume = high reimbursement)

Beginning in 2019* payments will be linked to quality and value

• Merit-based Incentive Payment System

• Alternative Payment Model*based on performance year of 2017

MACRA? MIPS? APM?

What we know?

Only one-fifth of physicians are “familiar” with new Quality Program

CMS Response: “Pick you Pace”

Final rules implementing MACRA are expected by November 2016

*The Physicians Foundation 2016 Physician Survey

Physicians Familiar With MACRA*

Medicare Access and CHIP Reauthorization Act (MACRA)

FEE FOR SERVICE FEE FOR VALUE

Dissolves Sustainable Growth Rate (SGR)

Creates Quality Payment Program

Two tracks:

Merit-based Incentive Payment System (MIPS)

Alternative Payment Models (APMs)

Payment methodology = proper clinical documentation & coding

Quality Track #1: MIPSStreamlines multiple independent programs in to ONE

The Physician Quality Reporting System (PQRS): focus on quality measurement and improvement

The Medicare Electronic Health Record (EHR) Incentive Program: focus on meaningful use to promote sharing of care information

The Value Modifier (VM) Program: focus on resource use

QualityAdvancing

Care Information

Clinical Practice

ImprovementActivities

Resource Use

(Cost)

50% 25% 10% 15%

MIPS Components DefinedQuality

Selection of outcome measures, population measures, PQRS measures

Advancing Care Information

Utilization of Electronic Health Record (e-prescribing, HIX, PHI, etc.)

Resource Use

Comparison of resources used to treat similar care episodes and clinical conditions groups across medical practices

Clinical Practice Improvement Activities

Patient Centered Medical Home, care coordination, shared decision making, safety checklists, expanding practice access

MIPS – Payment ChangesFor the first time in history, payment amounts for services providers deliver to Medicare beneficiaries will vary among the providers!

Some providers may potentially receive more than 30 percent greater payment amount than other providers based on higher performance

Payment adjustment type: positive, negative, or neutral

Performance Year PaymentAdjustment Year

Adjustment %

2017 2019 +/- 4%

2018 2020 +/- 5%

2019 2021 +/- 7%

2020 and after 2022 and onwards +/- 9%

Participation in MIPSParticipation in MIPS by:

o Individual*

o Group: Taxpayer identification number* (TIN)

MIPS eligible clinicians

*Year 1 & 2: Physicians, PAs, NPs, Clinical nurse specialists, Certified registered nurse anesthetists

*Year 3: Physical or occupational therapists, Speech-language pathologists, Audiologists, Nurse midwives, Clinical social workers, Clinical psychologists, Dietitians / Nutritional profession

Quality Track #2: APMNew approaches to paying for medical care through Medicare that incentivize quality and value!

Proposed Rules:

CMS Innovation Center model (under section 1115A, other than a Health Care Innovation Award)

MSSP (Medicare Shared Savings Program)

Demonstration under the Health Care Quality Demonstration Program

Demonstration required by federal law

CMS Innovation Center model

Quality Track #2: APMNew approaches to paying for medical care through Medicare that incentivize quality and value!

APM Checklist:

Use of quality measures comparable to measures under MIPS

Use of a certified electronic health record (EHR) technology

Assumes more than a “nominal financial risk” OR is a medical home expanded under the CMMI.

APM Qualifying Criteria Following criteria must be met in order to participate as an Advance APM:

Use of Certified electronic health record technology (CEHRT) 50% usage of CHERT by eligible clinicians

Requires MIPS Comparable Quality Measures At least One Outcome measure

No minimum requirement on quality measures

Requires APM Entities to Bear More than Nominal Financial Risk

APM: RISK Bearing TRACKTo qualify for APM, provider participants should be able to bear a certain amount of financial risk:

◦ Total risk, or the maximum amount of losses possible under the advanced APM, which must be at least 4 percent of the APM spending target

◦ Marginal risk, or the percentage of spending above the advanced APM benchmark (or target price for bundles) for which the advanced APM entity is responsible (i.e., sharing rate), which must be at least 30 percent

◦ Minimum loss rate—the amount by which spending can exceed the APM benchmark (or bundle target price) before the advanced APM entity has responsibility for losses—which must be no greater than 4 percent

APM Outlook:CMS notes in the fact sheet for its proposed rule regarding the Quality

Payment Program:

“For years 2019 through 2024, a clinician who meets the law’s standards for Advanced APM participation is excluded from MIPS adjustments and

receives a 5 percent Medicare Part B incentive payment.

For years 2026 and later, a clinician who meets these standards is excluded from MIPS adjustments and receives a higher fee schedule

update than those clinicians who do not significantly participate in an Advanced APM.”

APM Payment AdjustmentsFor years 2019 through 2024: 5 percent Medicare Part B incentive payment.

For years 2026 and later: Higher fee schedule update than those clinicians who do not significantly participate in an Advanced APM

What are our options*?4 approaches as we step in to 2017:

1. Test the Quality Payment Program

2. Participate for part of the calendar year

3. Participate for the full calendar year

4. Participate in an Advanced Alternative Payment Model in 2017

*As of September 2016

Need for outpatient CDI?

Difference between DRG Optimization &Hierarchical Condition Category Codes (HCC)?

DRG OPTIMIZATION: Unfortunate result for some hospitals as they transitioned towards Clinical Documentation Improvement (CDI) in the 1990s. Hospitals began to up-code/falsify diagnosis-related groups (DRGs) by “gaming” the system to maximize DRG payments.

HIERARCHICAL CONDITION CATEGORY (HCCs):

Helps capture accurate patient acuity in the outpatient setting and have associated risk value for diagnosis codes (Risk Adjustment Factor – RAF).

Unlike DRG Optimization (where optimization teams reviewed and coded DRGs – queries to providers), documentation and coding is provider driven and leading queries are not part of the outpatient workflow.

Setting the context: Case Study

Patient Name: Ms. Jones

Chief Compliant: A 85 year old white female, symptoms of UTI.

HPI: Patient is tired, less energy and poor appetite and had a heart attack (MI) 1 year ago. Patient has mild malnutrition, is frail and has lost 30 lbs in the past 6 months. Urinalysis performed which shows white cells, leukocyte esterase, and microalbuminuria. Serum creatinine is 1.8. Patient has been complaining of urinary discomfort, weakness, and has had dry and itchy skin for the past 6 months. Alcohol dependence, in remission.

Past Medical History: Urinary Artificial Opening (Active), Stable diabetes mellitus (DM), chronic kidney disease (CKD) exacerbated by diabetes, stable BKA, stable history of MI, UTI w/ serum creatinine 2.2 six months ago. Lab findings revealed CKD stage 4.

Plan: Glucophage 500 mg b.i.d. for DM. Cipro for UTI. Ensure supplements for malnutrition. Return to Clinic in 3 months. Referral to nephrologist for CKD4

Setting the context: Case StudyHCC Impact: Capturing more complete and accurate patient picture

Documented ConditionsICD10-CM

CodeCMS HCC Category

CMS Risk Score

Demographic Score Total RAF ScoreExpected Payment

Diabetes, Type II, Uncomplicated E11.9 19 0.1620.677 0.839* $671.20

UTI N39.0 - 0

Diabetes Mellitus w/ Renal

ManifestationsE11.29 18

0.508

0.677 4.031* $3224.80

UTI N39.0 - 0

Diabetic Nephropathy E11.21141

Trumped by CKD Stage 4

CKD Stage 4 N18.4 137 0.244

Mild Degree Malnutrition E44.1 21 0.856

Artificial opening, status code Z93.9 188 0.651

BKA Status Z89.519 189 0.675

Alcohol Dependence, in remission F10.21 55 0.420

Scenario 2: Accurate capture of patient’s true acuity and Risk Adjustment Scores:

Scenario 1: What we normally see:

*HCC codes/values are updated every year requiring constant changes to disease sets and patient acuity capture.

Discussed later in our presentation…

Why Documenting & Coding accurate patient acuity matters?

• WHAT: Assess, identify and report gaps in specific patient disease sets

• HOW: Targeted Retrospective Audits

ENSURE COMPLETE & ACCURATE

DOCUMENTATION

• WHAT: Accurately reflect the cost component of patient’s care

• HOW: HCC/Risk Adjustment Factor Capture

REFLECT COST OF CARE BY CAPTURING TRUE PATIENT

ACUITY

• WHAT: Holistic capture of quality measures

• HOW: HEDIS Quality Measures for Medicare Advantage Plans

IMPROVE QUALITY REPORTING

• WHAT: Ensure documentation matches services billed

• HOW: Targeted Retrospective Audits

REVENUE INTEGRITY

Provider Education

Audit Feedback

Patient Acuity

ENSURE COMPLETE & ACCURATE DOCUMENTATION

PURPOSE: Assess, identify and report gaps in specific patient disease sets

PROCESS:

o IDENTIFY: Utilize past claims data to generate audit sample based on patient acuity (prior month’s data)

o CONDUCT: Perform retrospective audits for each provider (50% of time spent)o REVIEW: Utilize coding guidelines to determine associated links within documentation.

o QUERY: Query as appropriate to seek clarity in provider’s documentation

DELIVERABLES:

Retrospective Chart Review Findings

Service Line Analysis (Top Diagnosis & CPT codes)

METRICS FOR SUCCESS:

- % of Clinical Notes Closed within 24 hours

- Provider Query & Response Rate

REFLECT COST OF CARE BY CAPTURING TRUE PATIENT ACUITY

PURPOSE: Accurately reflect the cost component of patient’s care

PROCESS:

o ANALYZE: Review clinical documentation to ensure documentation translates in to appropriate diagnosis codes.

o COMPARE: Review CMS published risk scores/categories to drive highest level of specificity in diagnosis codes.

o QUERY: As appropriate, query the provider to determine causal relationships between diagnosis codes. o GENERATE: Prepare pre/post assessment of provider’s documentation to reflect accurate patient acuity.

DELIVERABLES (personalized provider profile):

ICD10 Risk Adjustment Specialty Crosswalk

Risk Adjustment Patient Examples (provider specific)


- % of Non-RAF Codes

- # of RA Categories Utilized

IMPROVE QUALITY REPORTING

PURPOSE: Holistic capture of quality measures

PROCESS:

o REVIEW: Use 2017 HEDIS measures to ensure appropriate capture of quality measures for Commercial, Medicare and Medicaid payers.

o ASSESS: Review provider documentation to identify gaps in quality measures capture.

o PARTNER: Collaborate with care teams to provide consistent feedback on missed opportunities. o BUILD: Work with appropriate teams to load updated quality measure codes in EeMR. Assist with template

updates, as needed.


Category II codes capture by each provider (pre and post assessment)

Specialty Category II codes capture


- % of Quality Measures Capture for Key Indicators (BMI, Diabetes Management, Blood Pressure, Lipid Management, Preventive Screening, etc.)

- # of Template Updates (coding/documentation related)

REVENUE INTEGRITY

PURPOSE: Ensure documentation matches services billed

PROCESS:

o CAPTURE: Ensure all services are documented in the medical record (including ancillary services).

o VALIDATE: Confirm procedures support medical necessity and key documentation elements.

o QUERY: As appropriate, query the provider to determine causal relationships, seek clinical clarifications and medical decision making to support services billed.

o COMMUNICATE: Share overall documentation/coding findings to providers via faculty meeting or 1 on 1session.


FPSC Bell Curve Analysis

Procedure Specific Playbooks (drive standardization in documentation)


- # of Encounters

- wRVUs by Providers

- Medical Necessity Denials

Patient Panel Identification

Audit SheetProvider Patient Name MRN Date of Service Charge

Amount

ICD 10 Billed ICD 10 Audit Result CPT Billed CPT Audit Result Specificity in Documentation

Present? (Y/N)

Specificity in Diagnosis

Present? (Y/N)

Overall Audit Result

(CPT) - Over coded, under

coded, no change

Documentation Comments

(Problem list, medication list, A&P, etc.)

Standard Query ProcessRequest for Clarification-Associated Conditions

Dear Physician/PA/NP: ____________________________________________________________________ or other responsible provider:

For accurate coding and severity-of-illness compilation, this query is directed to you. When responding to this query, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular answer is desired or expected.

The pt has documented –

A cause-and-effect relationship between diagnoses may not be assumed and must be explicitly documented. Please document the cause-and-effect relationship, if any, between these conditions.

Diagnosis Specificity

Benchmarking with peers

Risk Adjustment Overview

Objectives

◦Discuss the meaning of risk adjustment

◦Discuss the meaning of hierarchical condition categories (HCC)

◦Review documentation requirements for accurate HCC capture

◦Review case studies

Risk Adjustment Factor (RAF) A “risk adjustment score” is determined by using a combination of demographic information in tandem with disease information as a predictive factor for calculating expected future health costs for members and beneficiaries.

The sicker the patient, the higher the RAF score.

Calculating the RAF ScoreTotal score of all relative factors related to one patient

for a total calendar year are derived from the combination of two scores:

Age & either community-based or institution-based

Medicaid disability and interaction with age and gender

Diagnoses reported on claims submitted for face-to-face encounters determines HCC categories

Interaction between certain HCC categories

Interaction between disease categories and disability status

Purpose of Risk Adjustment ScoresMedicare Care Advantage PlansCurrently active

Managed Care plans with “shared savings” incentivesCurrently active

Part of the Total Performance Score for Value

Based purchasingFuture state

Hierarchical Condition Categories (HCC)

Developed by CMS for Medicare Advantage plans

CMS Rx HCC model for Medicare Part D

2014 Model includes 79 condition categories with 25 “short-name” categories

Developed by the Dept. of Health & Human Services for commercial payors.

Used for a predictive factor of future healthcare costs, including medications and any necessary supplies.

CMS HCC HHS HCC

Application and Calculation of HCCsMedicare Advantage plans use to calculate “per member

per month” cost

Current year data as a predictive year risk

Diagnoses collected from claims submitted within a year◦ Diagnoses only collected from face-to-face encounters

◦ Eligible Providers are: Physicians

Nurse Practitioners

Physician Assistants

CRNA

Therapists

Psychologists

Podiatrists

HCC Breakdown

70,000+ ICD-CM codes included in…

189 hierarchical condition categories within…

79 HCC categories within…

25 “short name categories”

“Short Name Categories”

Infection Metabolic LiverNeoplasm Diabetes

Gastro-intestinal

Spinal

Vascular

Injury

Musculo-skeletal

Neurologic

Lung

Compli-cations

Blood

Arrest

Eye

Transplant

SubstanceAbuse

Heart

Kidney

Openings

Psychiatric

Cerebo-vascular

Skin

Ampu-tations

How HCCs are assessedIn risk adjustment models, certain diagnosis codes carry a “risk adjustment value” (RAF)

This is a cross between DRGs for facility coding and RVUs for professional coding

The more severe or complex a diagnosis within an HCC category, the higher the value.

If two or more conditions are coded from the same category, the diagnosis that is more sever will the trump any others from the same category

Documentation & RAF

No Coded Conditions

RAF Some Conditions Coded RAF All Conditions Coded (based on certified risk

adjustment coder)

RAF

76 y.o. female 0.437 76 y.o. female 0.437 76 y.o. female 0.437

Medicaid eligible 0.151 Medicaid eligible 0.151 Medicaid eligible 0.151

DM not coded 0.00 DM II no complications 0.118 DM II w/vascular manifestations

0.368

Vascular disease not coded

0.00 Vascular disease, no complications

0.299 Vascular disease w/complications

0.410

CHF not coded 0.00 CHF not documented 0.00 CHF coded 0.368

No interaction 0.00 No interaction 0.00 + Disease interaction “bonus” RAF (DM + CHF)

0.182

Patient Total RAF 0.588 Patient Total RAF 1.005 Total Patient RAF 1.916

PMPM $412 PMPM $704 PMPM $1341

Yearly Reserve $4,944 Yearly Reserve $8448 Yearly Reserve $16092

* All values are based on CMS 2014 Model 22 with hypothetical baselines

Variable Community Institution

Female

0-35 Years 0.197 1.169

35-44 Years 0.205 0.949

45-54 Years 0.263 0.915

55-59 Years 0.326 0.981

60-64 Years 0.392 0.986

65-69 Years 0.288 1.237

70-74 Years 0.348 1.145

75-79 Years 0.437 1.033

80-84 Years 0.539 0.922

85-89 Years 0.677 0.836

90-94 Years 0.815 0.705

95 Years and older 0.840 0.533

Table 1. 2014 CMS HCC Model Relative Factors for Community & Institutional

Medicaid and Originally Disabled Interactions with Age and Sex

Condition Community Institutional

Medicaid Female Aged 0.151 0.067

Medicaid Female Disabled 0.085 0.067

Originally Disabled Female 0.177 0.067

Additional Considerations when calculating Risk Adjustment Factors

Disease Coefficients Description Label Community Institutional

HCC1 HIV/AIDS 0.470 1.904

HCC2 Septicemia, Sepsis, SIRS 0.535 0.575

HCC6 Opportunistic Infections 0.440 0.344

HCC8 Metastatic Cancer/Acute Leukemia 2.484 1.203

HCC9 Lung & Other Severe Cancers 0.973 0.674

HCC10 Lymphoma & Other Cancers 0.672 0.412

HCC11 Colorectal, Bladder & Other Cancers 0.317 0.296

HCC12 Breast, Prostate & Other Cancers/Tumors

0.154 0.198

HCC17 Diabetes w/Acute Complications 0.368 0.474

HCC18 Diabetes w/Chronic Complications 0.368 0.474

HCC19 Diabetes w/o Complications 0.118 0.182

HCC21 Protein-Calorie Malnutrition 0.713 0.399

HCC22 Morbid Obesity 0.365 0.579


HCC23 Other Significant Endocrine & Metabolic Disorders

0.245 0.282

HCC27 End-Stage Liver Disease 0.923 1.083

HCC28 Cirrhosis of the Liver 0.399 0.351

HCC29 Chronic Hepatitis 0.251 0.351

HCC33 Intestinal Obstruction/Perforation 0.310 0.384

HCC34 Chronic Pancreatitis 0.286 0.095

HCC35 Inflammatory Bowel Syndrome 0.302 0.318

HCC39 Bone/Joint Muscle Infection/Necrosis 0.498 0.340

HCC40 Rheumatoid Arthritis & Inflammatory Connective Tissue Disorders

0.374 0.351

HCC46 Severe Hematological Disorders 1.136 0.794

HCC47 Disorders of Immunity 0.521 0.519

HCC48 Coagulation Defects & Other SpecifiedHematological Disorders

0.252 0.162

HCC54 Drug/Alcohol Psychosis 0.420 0.053

HCC55 Drug/Alcohol Dependence 0.420 0.053


HCC57 Schizophrenia 0.490 0.311

HCC58 Major Depressive, Bipolar & Paranoid Disorders 0.330 0.311

HCC70 Quadriplegia 1.234 0.650

HCC71 Paraplegia 1.052 0.539

HCC72 Spinal Cord Disorders/Injuries 0.509 0.280

HCC73 Amyotrophic Lateral Sclerosis & Other Motor Neuron Diseases

0.958 0.367

HCC74 Cerebral Palsy 0.045 -

HCC75 Myathenia Gravis/Myoneural Disorders& Guillain-Barre Syndrome/Inflammatory & Toxic Neuropathy

0.408 0.300

HCC76 Muscular Dystrophy 0.565 0.215

HCC77 Multiple Sclerosis 0.556 -

HCC78 Parkinson’s & Huntington’s Disease 0.691 0.173

HCC79 Seizure Disorders & Convulsions 0.284 0.144

HCC80 Coma, Brain Compression/Anoxic Damage 0.570 0.104

HCC82 Respirator Dependence/Tracheostomy Status 1.520 1.769


HCC83 Respiratory Arrest 0.802 1.169

HCC84 Cardio-Respiratory Failure & Shock 0.329 0.442

HCC85 Congestive Heart Failure 0.368 0.229

HCC86 Acute Myocardial Infarction 0.275 0.515

HCC87 Unstable Angina & Other Acute Ischemic Heart Disease

0.258 0.515

HCC88 Angina Pectoris 0.141 0.474

HCC96 Specified Heart Arrhythmias 0.295 0.262

HCC99 Cerebral Hemorrhage 0.339 0.216

HCC100 Ischemic or Unspecified Stroke 0.317 0.216

HCC103 Hemiplegia/Hemiparesis 0.581 0.061

HCC104 Monoplegia, Other Paralytic Syndromes 0.396 0.061

HCC106 Atherosclerosis of the Extremities with Ulceration or Gangrene

1.413 0.886

HCC107 Vascular Disease w/Complications 0.410 0.301

HCC108 Vascular Disease 0.299 0.107


HCC110 Cystic Fibrosis 0.417 0.364

HCC111 COPD 0.346 0.364

HCC112 Fibrosis of the Lung & Other Chronic Lung Disorders

0.274 0.260

HCC114 Aspirations & Specified Bacterial Pneumonias 0.672 0.285

HCC115 Pneumococcal Pneumonia, Empyema, Lung Abscess

0.200 0.285

HCC122 Proliferative Diabetic Retinopathy & Vitreous Hemorrhage

0.203 0.433

HCC124 Exudative Macular Degeneration 0.335 0.166

HCC134 Dialysis Status 0.476 0.509

HCC135 Acute Renal Failure 0.476 0.509

HCC136 CKD Stage 5 0.224 0.509

HCC137 CKD, Severe Stage 4 0.224 0.294

HCC157 Pressure Ulcer of the Skin w/Necrosis through to Muscle/Tendon/Bone

2.488 1.050

HCC158 Pressure Ulcer of the Skin w/Full Thickness Skin Loss

1.338 0.435


HCC161 Chronic Ulcer of Skin, Except Pressure 0.536 0.311

HCC162 Severe Skin Burn or Condition 0.411 0.327

HCC166 Severe Head Injury 0.570 0.104

HCC167 Major Head Injury 0.163 -

HCC169 Vertebral Fractures w/o Spinal Cord Injuries

0.497 0.228

HCC170 Hip Fracture/Dislocation 0.446 -

HCC173 Traumatic Amputations & Complications 0.265 0.122

HCC176 Complications of Specified Implanted Device/Graft

0.566 0.522

HCC186 Major Organ Transplant or Replacement Status

0.891 0.515

HCC188 Artificial Openings for Feeding or Elimination

0.651 0.594

HCC189 Amputation Status, Lower Limb/Amputation Complications

0.779 0.468

Variable Description Community Institutional

CANCER_IMMUNE Cancer*Immune Disorders 0.947 -

CHF_COPD CHF*COPD 0.259 0.221

CHF_RENAL CHF w/Renal Disease 0.317 -

COPD_CARD_RESP_FAIL COPD*Cardiorespiratory Failure 0.456 0.506

DIABETES_CHF Diabetes*CHF 0.182 0.189

SEPSIS_CARD_RESP_FAIL Sepsis*Cardiorespiratory Failure 0.456 0.506

ARTIF_OPENINGS_PRESSURE_ULCER

Artificial Openings for Feeding or Elimination*Pressure Ulcer

- 0.282

ASP_SPEC_BACT_PNEUM_PRES_ULCER

Aspiration & Specified Bacterial Pneumonias

- 0.495

COPD_ASP_SPEC_BACT_PNEUM COPD*Aspiration & Specified Bacterial Pneumonia

- 0.319

SCHIZOPHRENIA_CHF Schizophrenia*CHF - 0.212

SCHIZOPHRENIA_COPD Schizophrenia*COPD - 0.389

SCHIZOPHRENIA_SEIZURES Schizophrenia*Seizure Disorders & Convulsions

- 0.452

DISEASE INTERACTIONS

Variable Description Community Institutional

SEPSIS_ARTIF_OPENINGS Sepsis*Artificial Openings for Feeding or Elimination

- 0.553

SEPSIS_ASP_SPEC_BACT_PNEM Sepsis*Aspiration & Other Specified Bacterial Pneumonias

- 0.339

SEPSIS_PRESSURE_ULCER Sepsis*Pressure Ulcer - 0.522

DISEASE INTERACTIONS

YOUR TURN!!!

Creating your CDI Plan

Assess◦ Identify your most commonly used ICD10-CM codes, specifically those of chronic

conditions or injuries

◦ From those, identify any unspecified or “not otherwise specified” codes ◦ Example: J40 “Bronchitis, not specified as acute or chronic” (no HCC value) versus J41.0 “Simple chronic

bronchitis” (HCC 111)

◦ Identify patients who have had these codes submitted on their claims in the past 6 months and have a certified auditor/certified coder review the charts to perform a gap analysis of the documentation which may be preventing more specific coding.

◦ Review how providers are selecting the diagnosis codes that are being submitted (paper encounter form, EMR “favorites” list, etc.)

Implementation◦ Meet with the providers to discuss findings.

◦ Identify simple terms for providers to use in their documentation that can provide the necessary information to code to the highest specificity.

◦ Identify and explain gaps and/or deficiencies, as well as opportunities.

◦ Work with your IS/IT team to assist in creating more intentional templates in EMR. This is especially helpful for specialists, or for particular chronic conditions.

◦ Eliminate paper encounter forms if possible.

◦ Identify a Physician Champion if your practice is large enough, and enlist their help in educating the others. They can also offer great clinical feedback to the coders and/or auditors.


Sustainability◦ Ongoing claims data analysis to monitor unspecified code usage

◦ Continued focused audits and feedback, especially to the providers most at risk

◦ Continued educational efforts using actual examples.

◦ Monitoring of claims not being paid upon initial submission and coming back with the request for “more information (CO-16), or “medical record requests” (M127)

◦ The use of technology wherever possible to allow your providers to concentrate on taking care of the patient instead of “being a coder”…


Sample Progress Note

Patient: Female, age 74Chief Complaint: Follow up for multiple medical problems.HPI: DM2: Tries to watch her diet, average BS 110-180, compliant with Lantus 20 units QHSDiabetic Polyneuropathy: Burning in her feet improved on Neurontin x 3 mon use.PVD: Walks at mall daily, mid-calf pain after about 7 minutes, no history of injury, no CP, or SOB.Functioning colostomy secondary to UC. No change in output, no increased redness, followed by GI every six months S/P right great toe amputation. Denies any new foot or toe lesions.ROS: See HPICurrent medications, allergies and PMSH reviewed in HER today and no changes since last visit on April 14, 2015.Exam:BP 112/72 P76 WT 245 HT 5’3” BMI 41.5Older female NADHeart: Normal S1 S2 w/o murmurLungs: Easy respirations, CTAAbd: Soft, non-tender, colostomy intact, no ulcerations, amputation site well healed.Monofilament testing shows decreased sensation bilaterally.

Typical Assessment & Plan:1. Controlled DM Type II (EII.9) (E11.41)2. Peripheral Vascular Disease,

unspecified (I73.9)

Plan: Continue current diet and medication regime. Referral given for dilated retina exam. Referred for Diabetic Education. Fasting CMP & A1c prior to next appointment.

Demographic RAF:Female age 74 (0.348)

Diagnosis/es RAF: E11.9 DM II w/o complications

• HCC 19 (0.118) I73.9 PVD

• HCC 108 (0.299)

DX RAF: 0.417Demographic RAF: 0.348Total RAF: 0.765

Complete Assessment & Plan:1. Controlled DM II with neurologic manifestations (E11.41)2. Stable Peripheral Vascular Disease (I73.9)3. Long-term use of insulin (Z79.4)4. Artificial Opening Status-colostomy (Z93.3)5. S/P great toe amputation (Z89.411)6. Morbid Obesity (E66.01)

Plan: Continue current diet and medication regime. Referral given for dilated retina exam. Referred for Diabetic Education. Fasting CMP & A1c prior to next appointment

Demographic RAF:Female age 74 (0.348)

Diagnosis/es RAF: Morbid Obesity/BMI 41.5

• HCC 22 (0.365) E11.41 DM II w/neurologic complications

• HCC 18 (0.368) I73.99 PVD

• HCC 108 (0.299) Z93.3 S/P colostomy

• HCC 188 (0.651) Z89.411 right great toe amputation

• HCC 189 (0.779) DX RAF: 2.462Demographic RAF: 0.348

Total RAF: 2.810

Now your turn…

85 y.o. white female, symptoms of UTI.

HPI: Patient is tired, less energy and poor appetite and has had a heart attack (MI) 1 year ago. Patient has mild malnutrition, is frail and has lost 30 lbs. in the past 6 months. UA performed shows white cells, leukocyte esterase, and microalbuminuria. Serum albumin is 3.0 g/Dl. Serum creatinine is 1.4. Patient has been complaining of urinary discomfort, weakness, and has had dry and itchy skin for 6 months.

PMH: Stable DM, CKD exacerbated by DM, Left stable BKA, stable history of MI. GFR = 17 ml/min revealed CKD Stage IV.

Plan: Glucophage 500 mg. b.i.d. for DM, Cipro for UTI. Ensure supplement (drink) for malnutrition. RTC in 3 months. Referral to nephrologist for CKD IV.

The exercise is to review the note, and using the HCC table identify any conditions that could have an HCC category and value. Don’t forget to add the demographics as well.

Gender Age HCC Description Community Institutional RAF

Female 85 N/A Demographic Yes No 0.677

HCC18 DM w/renalmanifestations

0.368

HCC137 CKD Stage IV 0.224

HCC189 Right BKA 0.779

HCC 21 Mild protein malnutrition

0.713

Total: 2.761

Resourceshttps://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Risk-Adjustors.html

https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Risk-Adjustors.html

Questions? Comments?

Building a Successful Outpatient Clinical...

Documents

Transcript of Building a Successful Outpatient Clinical...