Modernize your CDI Program for Quality Outcomes

Kelly Gates, BSN, MHA, CCDSVP of Provider Solutions, Ciox Health

Objectives

Identify current quality initiatives introduced by the Affordable Care Act, which impact hospital reimbursementIdentify the impact that quality initiatives will have on healthcare organizations

for the longer termDiscuss how risk adjustment impacts hospital reimbursement Discuss how these quality requirements impact traditional CDI workflowRelate the differences in coding and CDI roles in identifying, reviewing and

assigning codes for risk adjustment Apply learned concepts to explore potential opportunities at your hospital

Overview of Evolving Reimbursement

Hospital Quality Overview

Patient Protection and Affordable Care Act (PPACA) of 2010 (Obamacare) created several new Medicare programs intended to improve health care quality, using “pay-for-performance” payment strategies CMS uses claims data to identify and incentivize hospitals to

improve patient outcomes

Requires CMS to publicly report performance

• Hospital Readmissions Reduction Program few exclusion hospitals • Hospital Value Based Program impacts >3000 Hospitals • Hospital-Acquired Condition (HAC) Reduction Program

Hospital Quality Outcomes, Here to Stay

CMS 2018 National Quality Measures Report CMS will continue to assess the impact of quality measures on

patients and health outcomesFocus on: Preventable health care harm Readmissions to hospitals Risk adjusted mortality Risk adjusted total cost of care Management of chronic conditions

00000000000000

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Quality Penalties: How much is Your Hospital Losing?

HRRP 3% HVBP 2% IQR 2% HAC 1%

H O S P I TA L

Total8%

• CMS collects IPPS data under the Hospital Inpatient Quality Reporting (IQR) Program

• Goal: Driving quality improvement through measurement, accountability and transparency

• Selected measures are tied in the form of a payment penalty

Long-term care hospitals Critical access hospitals Rehabilitation hospitals and units Psychiatric hospitals and units Children’s hospitals PPS-exempt cancer hospitals Maryland Hospitals*

Excluded Hospitals

Claims Based Outcome Measures

Risk Adjusted

Mortality

• AMI• CABG• COPD• HF• PNA• CVA

Readmissions

• AMI• CABG• COPD• HF• PNA• CVA*• All cause• Hip & Knee

Complications

Patient Safety Indicators

• PSI 04: Death Rate among Surgical Patients

• PSI 90 Patient Safety and Adverse Events

Excess acute Care days

• AMI• HF• PNA

*Proposed removal by 2020

Transparency of Hospital Data

Public Transparency of Data

Source: http://www.hospitalsafetyscore.org

Outcome of Traditional CDI programs?

http://www.hospitalsafetygrade.org

Opportunity?

www.medicare.gov/hospitalcompare

Hospital Readmissions

Hospital Readmissions

• Established under the Affordable Care Act, began in 2012 • Only counts if > 25 or more eligible discharges • ERR=predicted-to-expected readmissions • Threshold of 1.0 is applied to all hospitals, if the ERR >1.0 Penalty • Maximum penalty is 3% • Payment reductions are applied to all Medicare FFS base operating

DRG payments for the upcoming fiscal year (prospective)• Starting in FY 2019, HRRP penalties will be based on a hospital's

performance relative to other hospitals with a similar proportion of dual eligible patients (True Peer Grouping).

Hospital Readmission Reduction Penalty(HRRP)

HRRP

• Penalties are currently based upon retrospective data• To make comparisons fair, hospitals’ 30-day readmission results

are "risk-adjusted”• Medicare beneficiaries enrolled in Medicare Advantage are not

included Risk Adjusted factors:

• Age• Gender• Past Medical History• Other POA chronic conditions

Hospital Readmission Reduction Penalty(HRRP)

AMI PNACHFHips & Knees

CABGCOPD

30 days

READMISSION

Discharge

• Risk adjustment impacts outcomes • Documented and coded chronic conditions predict risk

for adverse outcomes

Getting Started

Useful Resources: 1. CMS

2. Quality Net• Hospital Specific Reports (HSRs) contain detailed discharge level data on your readmission results• HSRs are shared with hospitals via the QualityNet Secure Portal

Penalty factor

Over 1.00 in excess ratio indicates an outlier penalty

Understanding Your Hospital Data

Value Based Care/Pay-for-performance

• MedPar data 2017• Penalties apply to all

Medicare FFS Inpatient discharges

• Base rate reduction

Modernize Your CDI program

Traditional & Modern CDI Programs

Focused on DRG matches

Con-concurrent review

Impact on Revenue

MCC/CCSOI ROM

Focus on the now

Focus on ICD-10 specificity

Post discharge Pre-bill review

Impact on Outcomes

Risk Adjustment

Driven by Data

Traditional CDI Programs

Modernized CDI programs

Physician Documentation

What Hasn’t Changed

• Goal: adequate, clear physician documentation• The identification of a chronic condition is irrelevant to coding if

not documented by the provider• Codes are assigned based upon provider documentation

issue isn’t with coding it’s with the documentation• All diagnoses must include an assessment/evaluation and

treatment

Clinical Documentation Quality Improvement (CDQI)

• Data drives the compass for improvement• Post-discharge, pre-bill structure• Coding & CDI partnership• Different Focus

• Unspecified codes which often do not move the MS-DRG needle

• Coordinated effort not who made the impact

Getting Started• Utilize data to target focus efforts• Implement post-discharge, pre-bill review• Hire an expert to get you started• Outsource• Technology/CAC

CDQI Staffing for Quality Outcomes

• Dedicated team• Estimate the volume of

discharges• Extrapolate Medicare FFS payer • Measure impacts

CDQI Staffing for Quality Outcomes• Assemble a team and educate on the differences of the focused

review

Risk Variables: Sleep Apnea, History of mechanical ventilation

Focus on where to move the needle• Identify the measure population for which risk adjustment is to

be used• Focus on where you can impact

ICD-10-CM Other Diagnosis Codes (0 to 17 codes)ICD-10-CM Principal Diagnosis Code !

Identifying what will influencing the targeted measure

https://www.qualityindicators.ahrq.gov/Downloads/Modules/PSI/V41/PSI_Risk_Adjustment_Tables_V41a.pdf

Know what metrics to track• Identify and measure your impact:

Prospective penalty• Likely will not impact the DRG

assignment• Track and Trend• Number of cases reviewed• Number of queries• Context of Query

Risk Adjustment | A C T U A L C H A R T R E S U L T

OsteoarthritisPrinciple Diagnosis

Post-op hypotension

Unspecified cirrhosis

Acute Blood Loss Anemia

Retention of urine

CC 28= 0.399

Chronic Hep C

Portal Hypertension

Thrombocytopenia(Result of a Query)

CC 27

CC48

CC 29+ 0.251 =

+ 0.252 =

+ 0.923 =

Co-morbidity (CC)

+1.426

Hospital Coded Chart CDQI Impact

Adjusted Risk Score:After CDQI Review

MS-DRG 470: TOTAL KNEE REPLACEMENT W/O MCC

1.8250.399

• CDQI focus extends to include the 40% of ICD-10 codes which are not a MCC/CC but impact risk adjustment

• Does not impact the MS-DRG assignment

Thank You!

Questions?