Day1PP8 Christiana Care Hosp SCarrier KFrosch Final · Title: Microsoft PowerPoint -...

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Development of Ambulatory CDI at Christiana Care Hospital

Karen Frosch, CCS, CCDS, CRC, CPHQCDI Project ManagerChristiana CareNewark, DE

Susan A. Carrier, RN, BSN, MBA, CCDS, CPCAmbulatory CDI Program ManagerChristiana CareNewark, DE

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Learning Objectives

• At the completion of this educational activity, the learner will be able to:

– Illustrate the timeline and support required for an ambulatory CDI program

– Demonstrate the CDI process

– Demonstrate tools needed

– Illustrate queries utilized

– Provide examples of tools to leadership and resultant trends

2018 Copyright, HCPro, a brand of Simplify Compliance LLC. All rights reserved. These materials may not be copied without written permission.

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Christiana Care Health System – Who We Are

• 150+ patient and family advisors

• Outpatient visits: 582,257

• Home healthcare visits: 312,537

• 22nd in U.S. admissions: 53,259

• 28th in U.S. surgeries: 39,102

• 21st in U.S. ED visits: 197,340

• 31st in U.S. births:6,545

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Christiana Care Health System – Who We Are

Our major facilities include• Christiana Hospital and SurgiCenter

913 bedsOnly Level I trauma center on the East Coast corridor between Baltimore and PhiladelphiaTeaching hospital

• Wilmington Hospital and SurgiCenter241 bedsTeaching hospital

• Middletown freestanding emergency department• 16 primary care practices• 3 resident site practices• > 50 specialty and/or provider‐embedded practices• Independence at Home (IAH)

700 patients


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Recognizing the Need

• Contract negotiations with our Medicare Advantage plans identified low risk scores for our patient population

• Administration realized the need to capture HCCs at the time of the patient’s visit and turned to our inpatient CDI program for guidance on how to implement CDI in our ambulatory/primary care practices

• Establish the goals and scope of the program

– HCC capture only?

– E/M levels and HCCs?

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Where/How to Begin?

Learn & understand:

What HCCs/risk adjustment are

Documentation required to support HCCs

Coding rules guiding the capture of HCCs

• Many organizations are offering courses, education modules, etc. on HCCs


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Inpatient CDI vs. Outpatient CDI

Similarities Differences

Capturing documentation concurrently Provider workflows

ICD‐10 diagnosis specificity is the same Outpatient coding rules vs. inpatient coding rules

Metrics are needed Metrics similar to inpatient but HCC‐focused

Query process needed

Physician communication/education is essential

Physician champion is essential

Administration support is essential

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Inpatient CDI With an Outpatient Twist

• Become familiar with the primary care office routine

– Establish contacts/champions

– Understand provider documentation workflow

• It may not be the same for everyone

– Determine how to educate and communicate with providers

• This is a new concept – a lot of education and feedback is essential


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Query Process

• Draft a query process

– Work with providers to establish what works for them

• Be prepared to tweak the process

– Queries must be compliant and follow AHIMA/ACDIS guidelines

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Metrics

• Determine what metrics will demonstrate a return on investment – understanding risk score reporting is not timely

– # of reviews, queries, HCCs captured, etc.

• Establish a mechanism for capturing metrics

– Electronic vs. Excel spreadsheet


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Hire a CDI Specialist

• RN vs. coder vs. both

– This is not an entry‐level position

– Depends on scope and goals of program

– Excellent communication skills a must

– Clinical and coding knowledge required

• Develop the CDI specialist workflow

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Ambulatory CDI Specialist Evolution


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Ambulatory CCHS Goal = Collaboration

• Ensure complete documentation of findings, diagnoses, and treatment in the patient health record, thereby improvingthe CCHS Risk Adjustment Factor Score over the baseline score for our Medicare Advantage patient population (Medicare in NJ practices and homecare), through collaborationwith our primary care providers that reflects the severity of illness and supports accurate ICD‐10‐CM diagnosis capture

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Implementation

• Create list of Medicare Advantage patients with upcoming appointments to family medicine practitioners in Delaware practices, Medicare in NJ, and Independence at Home

• Pre‐encounter documentation review of prior 1–2 years with attention to potential chronic condition gaps

• Generate provider query with supportive documentation of potential missed or unspecified chronic conditions prior to encounter

• Post‐encounter documentation review for query response

• Correction of bill to capture corrected documentation if not completed by the provider

• Data entry in Excel worksheet for each medical record reviewed


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The Query Process: Electronic Query

© 2018 Christiana Care Health Services, Inc., All rights reserved

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The Query Process: Templates

• Depression• BMI• Medication indication• Prior year diagnoses• Chronicity• Ruled in/out• Respiratory• Diabetic manifestations• Dependence• Pressure injury• Diabetes with neurological complications• Hepatitis• Acute vs. history• Diabetes with retinopathy• Wet versus dry AMD• Documentation clarification (generic)


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The Query Process: Compliance

• Documentation clarification is required to meet accuracy in coding and severity of illness reflection for your patient …

• … If clinically appropriate and you are monitoring, evaluating, assessing, and treating, please address in your assessment and add to your charge.

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The Query Process: Top Queries


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Recording the Data in Excel

Review Date

Reviewer

Patient name

Date of birth

Appointment

Payer/payer comments

Location

Provider

Comments

Query needed

Query

HCC

HCC coefficient

Follow‐up date

Response

Correct code

Correction completed

Necessary follow‐up

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Monthly KPI to Leadership: Overview

• Payer RAF change over time• Program success:

‐Response rate‐Projected RAF/$ capture‐Missed opportunity RAF/$

• Coding errors, RAF/$ • Unsupported codes• Top queries


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Monthly KPI to Leadership: By Site and Provider

• High volume practices• Query rate

Program success at site level: ‐Response rate‐Projected RAF capture ‐Missed opportunity

• Coding errors • Unsupported codes

May‐18

# of charts

reviewed

# reviewed charts needing queries

total # of queries

queries lost 2/2 Canceled encounter/AWV

Total queries for

patients seen

# of HCC queries

# of Affirmati

ve response

Response Rate

# incorrect codes

RAF Captured

RAF missed

58 30 50 10 40 40 34 85.0% 7 6.004 1.688

23 15 20 7 13 13 2 15.4% 1 0.448 3.446

177 82 135 26 109 109 84 77.1% 23 21.029 9.088

5 2 7 0 7 7 0 0.0% 0 0.000 1.906

7 5 10 1 9 9 7 77.8% 2 2.354 0.637

48 22 39 8 31 31 20 64.5% 2 3.599 3.07

11 6 10 1 9 9 3 33.3% 1 0.736 1.754

13 5 7 2 5 5 2 40.0% 1 0.486 1.379

38 24 33 8 25 25 20 80.0% 2 6.051 1.373

43 25 34 5 29 29 25 86.2% 8 3.790 1.749

53 25 36 9 27 27 19 70.4% 6 5.144 4.059

28 10 16 5 11 11 9 81.8% 0 2.827 0.733

16 11 17 4 13 13 8 61.5% 8 2.082 1.904

17 10 15 6 9 9 2 22.2% 1 0.118 4.423

4 3 4 1 3 3 2 66.7% 1 0.118 0.660

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Trends From KPI


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Trends From KPI

• Higher volume of queries in first quarter• More charts reviewed at year end

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Trends From KPI

• Higher volume of queries in first quarter• Less overall queries as concept accepted

(learning curve)


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Implementation: Other Needs

• Collaborate with physician champions to ID potential solutions to provider workflow obstacles

• 1:1 provider collaboration with CDI specialist at site

• Documentation tips

• Depression

• History vs. current

• The “Z” code

• DM and BMI

• Quality Corner of monthly medical group provider newsletter

• What is an HCC/RAF?

• Depression

• History vs. current

• M.E.A.T.

• Functional quadriplegia

• Peer‐to‐peer support from physician champions

• New provider training – biweekly (inpatient and outpatient)

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Documentation Tip Examples



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Captain Horatio Chronic Condition (HCC)

Morbid obesity .365

Exudative AMD .335

ETOH dependence .420

? cirrhosis .399? malnutrition .713

Ascites (? CHF; portal HTN) .368

COPD .346

Chronic respiratory failure .302

Total RAF 4.633

with vascular .368DiabetesAmputation .586



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Obstacles

• Ambulatory/outpatient CDI programs are uncharted ventures nationally with few resources

• One CDS (until 9/2017), 18 family medicine sites

• Risk adjustment and CDI learning curve for the primary care practices

• Compliance and legal department (fear of upcharging)

• Transitioning to a new EMR (CCHS using 2 EMRs during transition)

• Measurement of actual success due to CMS lag in diagnosis verification (data collection applied to “projected” analysis)

• Providers code their own charts

– Incorrect codes

• Diagnosis does not match documentation

• Diagnosis addressed with insufficient MEAT

• Coding guidelines not followed (clinical culture vs. coding awareness):

‐Diabetes link to complication

‐History vs. acute/active conditions

‐Lack of specificity

– Delayed claim submission (5‐calendar‐day submission window from date of encounter)

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Lessons Learned

• Ability to adapt to the variability of documentation workflow from provider to provider is key for optimal query response.

• Continued feedback, engagement, and education with the providers is critical to successful outcomes.

• Clinical leadership support continues to be essential to provider buy‐in.

• Ambulatory/outpatient CDI programs are uncharted ventures nationally, so there are few resources on which to base program implementation.

• Because actual risk scores are only reported once a year, it is difficult to measure actual success, so you need to demonstrate success in other ways. Data collection and analysis is important.


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Path Forward

• Introduction of HCC dashboard in EMR

• New workflow for clinical documentation department and providers

• Ambulatory CDS electronic worksheet development for tracking and reporting

• Expansion of CDS support to specialty practices (cardiovascular, endocrine, etc.)

• Learning curve promotion and program excellence to ACO members

• Billing cycle closure with process for denial analysis and resultant education to the provider

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Thank you. Questions?

Karen Frosch ‐ [email protected] Carrier ‐ [email protected]

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.


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