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Outpatient CDI Implementation, Integration, and Issues

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Outpatient CDI Implementation, Integration, and Issues NYHIMA 79th Annual Conference Tuesday, June 3, 2014 Mel Tully MSN, CCDS, CDIP A Strategic Opportunity HCCs are ... – PowerPoint PPT presentation

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Title: Outpatient CDI Implementation, Integration, and Issues


1
Outpatient CDI Implementation, Integration, and
Issues
  • NYHIMA 79th Annual Conference
  • Tuesday, June 3, 2014
  • Mel Tully MSN, CCDS, CDIP

2
ICD-10 Will Launch
3
Key Discussion Points
  • Current state of Outpatient CDI Programs
  • Background and structure of Medicare Advantage
    (MA) program
  • CMS Hierarchical Condition Categories (HCCs) and
    HCC model
  • Integration of current inpatient CDI and
    outpatient CDI
  • CDI role in outpatient denials
  • Education for clinical documentation specialists,
    coders, and providers

4
Current State - Outpatient CDI Program
  • Hospital Outpatient
  • Most hospitals have implemented inpatient CDI
    programs, outpatient CDI has not been a focus
  • Likely because hospitals are financially
    strapped,
  • Have many competing priorities,
  • Little to no data available on the success of
    outpatient CDI
  • Outpatient volumes are very high and hospitals
    cannot afford to staff CDI programs in these
    areas
  • Hospitals focus on Revenue Integrity functions
  • Medical Necessity Audits and Charge Master/Charge
    Capture through Revenue Integrity Specialists
    with a non-clinical focus
  • Physician Office
  • Physicians are reimbursed based on E/M and CPT
    codes and do not have a good understanding of how
    critical clinical documentation can be to
    preventing denials.
  • E/M Auditing is a high demand services. Most
    physicians, whether owned or independent have an
    external vendor perform an annual E/M Audit as
    part of their Compliance Plan. However,
    physicians are very price sensitive for this
    service.

5
Physician Engagement for OP-CDI
  • Accurate clinical documentation is essential for
    quality patient care. 
  • Over recent years, based largely on the MS-DRG
    system, physicians have become aware of the
    impact of accurate and complete clinical
    documentation on physician profiles, morbidity
    and mortality data, and hospital reimbursement. 
  • With the rapid industry transition to
    quality-based payment, physicians have an even
    greater incentive to understand and assure
    accurate documentation. 
  • Many physicians are now receiving financial
    incentives under Medicare Advantage programs. 
    Few understand the revenue impact of complete and
    accurate documentation in all clinical settings. 
  • With the advent of ACOs and other integration
    models, physicians are increasingly accepting
    financial risk associated with patient management.

6
Medicare Advantage and CMS Hierarchical Condition
Categories
7
Medicare Advantage (MA) (Part C) Medicare Risk
Adjustment
  • Type of Medicare health plan
  • Contracts with CMS to provide benefits
  • Purpose of the CMS-HCC model is to promote fair
    payments to MA plans that reward efficiency and
    encourage high quality care for the chronically
    ill.
  • Part A and B, and oftentimes including Part D
    (RxHCC)
  • Extra dental, vision, hearing and preventive
    services
  • Some optional services such as exercise classes
  • Plan receives payment for each member from CMS
  • Payment based on member predicted health status
    and demographic characteristics
  • 2013 enrollment 14.4 M (28)
  • Up nearly 10 since 2012

8
HCCs
  • HCC concept similar to DRGs
  • Each member (patient) has Risk Adjustment Factor
    (RAF) score
  • Organization average RAF score similar to case
    mix
  • Score of 1 represents typical patient
  • Less than 1 is healthy patient
  • Greater than 1 likely patient utilizes greater
    resources
  • Certain diagnoses/status increase RAF
  • Similar to CCs and MCCs (75 are classified as
    CCs/MCCs)
  • Usually chronic conditionsbut not always
  • Specific documentation coding increases the
    mapping likelihood
  • Reported for certain encounters based on setting
    provider type

9
HCC Uses
  • Medicare Advantage Capitation Payment
  • Shared Savings Program
  • Accountable Care Organizations
  • Historical benchmark expenditures adjusted based
    on CMS-HCC model
  • Medicare Physician Quality and Resource Use
    Reports
  • Value Based Purchasing Initiatives (Bundled
    Payments)

10
Risk Adjustment Status
  • Currently payers receive most benefit
  • Some physicians incentivized, especially in CA
  • ACA is changing environment, increasing provider
    stake
  • Accountable Care Organizations
  • Patient Centered Medical Homes
  • Many current vendors focus on home visits to
    members because insufficient OP documentation
  • MA plan enrollment increasing

11
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12
Key Analytics for HCC Capture Where is HCC data
collected?
Physician Documentation!!
  • Medicare claims and encounter data
  • Early intervention to ensure quality clinical
    outcomes HCC CDS
  • Retrospective and prospective reviews including
    chart audits
  • Health status assessment each year Patient
    Summary Visit
  • Monitored
  • Evaluated
  • Assessed
  • Treated
  • Quarterly review of members to assess patient
    data
  • Health status above/below 1
  • Jumps in RAF scores

13
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14
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15
Diagnosis SourcesProvider Types
  • Diagnoses documented by select provider types are
    appropriate for coding and reporting for MA
    coding.
  • MD or DO
  • OD Doctor of Optometry
  • DC Doctor of Chiropractor
  • DDS Doctor of Dental Surgery
  • DO Doctor of Osteopathy
  • DPM Doctor of Podiatry
  • All NP, CNS, PA
  • Therapistsexcept respiratory
  • LCSW/CSW Licensed Clinical Social
    Worker/Clinical Social Worker
  • CWCN/CWOCN Certified Wound Care/ostomy Nurse

16
Disease Hierarchies
  • Address situations when
  • Multiple levels of severity for a disease or
    clinically related
  • Payment based only on most severe and costly
    manifestation of disease
  • Varying levels of associated costs
  • ..are reported for the same patient
  • Hierarchies are published in the Rate Announcement

17
Figure 2-3 Clinical vignette for CMS-HCC (version
12) classification community-residing,
76-year-old woman with AMI, angina pectoris,
COPD, renal failure, chest pain, and ankle sprain
18
Hierarchical Condition Categories Rules
  • Although HCCs reflect hierarchies among related
    disease categories, for unrelated diseases, HCCs
    accumulate
  • For example, a male with heart disease, stroke,
    and cancer has (at least) three separate HCCs
    coded, and his predicted cost will reflect
    increments for all three problems.
  • So unlike DRGs, there may be several HCCs
    assigned to an individual

19
Breakdown of HCC
  • 3033 ICD-9 codes are mapped to 87 categories
    (11,312 ICD-10 CM codes)
  • HCC logic is imposed on certain disease groups
  • The HCC model is cumulative, so that a patient
    can have multiple diagnoses assigned
  • Each diagnosis is factored into the members risk
    profile which calculates an individual RAF score
    (Risk Assessment Profile)
  • RAF score ambulatory CMI and is calculated
    annually

20
Hierarchical Condition Categories (HCC) Why you
should get to know them now
  • The Medicare risk adjustment payment system uses
    clinical coding information to calculate risk
    premiums for Medicare Managed Care Organizations
  • HCC payments are linked to the individual health
    risk profiles for each member in the plan
  • HCC codes are captured through accurate physician
    documentation

21
Heres How the System Works
  • If the average risk score for the overall
    population is defined as 1.0, a healthy young man
    might receive a score of 0.4 based on historical
    claims data, while a young woman with asthma
    might be scored at 1.5, and an older person with
    diabetes might be scored at 2.3.
  • A plan having an aggregate score of 1.2 for its
    enrollees would receive a 20 percent add-on to
    its average per person payments, while a plan
    with an aggregate score of 0.8 would experience a
    20 percent reduction in payments.
  • In practice, individual risk scores, built from
    data on patient demographics, disability,
    institutional status, and diagnoses, are used to
    help determine monthly payments made to plans for
    each person enrolled in Medicare Advantage,
    Medicare Part D prescription drug benefits, and
    many state Medicaid managed care programs.

22
CDI Case Study
23
Risk Adjustment 101 Case Study
24
HCC Calculation
25
Expect Audits to Validate Coding
  • Upcoding can undermine risk adjustment if it
    distorts the actual health-risk profile of a
    plan, for example, by suggesting that the people
    that the plan has enrolled are actually sicker
    than they really are.
  • Expect audit plans to enforce coding
    integritythat is, consistent use of diagnosis
    codes to negate any effect of upcoding.

26
Specificity Opportunities
  • Depression vs major depression (type)
  • Asthma vs chronic obstructive asthma/emphysema/chr
    onic bronchitis
  • Bronchitis vs chronic bronchitis
    (acuity/chronicity)
  • CAD vs angina/unstable angina (severity)
  • Cardiac dysrhythmia vs atrial fibrillation
    (specificity)
  • CVA vs late effect CVA/hemiplegia (current vs
    late effect)
  • Diabetes and PVD vs. Diabetic PVD (cause/effect
    relationship)
  • Status of cancer is unclear and treatment is not
    documented
  • Chronic conditions not documented once per year

27
Common Documentation Challenges
  • Problem Lists
  • Not updated
  • Title (Active, Chronic, Concurrent)
  • Past Medical History (PMH)
  • Current conditions impacting encounter documented
    hereand no where else in the documentation
  • History of diagnoses
  • Coding a past condition as active (CVA, CA, AMI)
  • Coding history of when condition is still active
    (COPD, CHF)
  • History of CHF on Lasix vs. Compensated CHF,
    stable on Lasix
  • Medicationbut no coordinating diagnosis
  • Ostomy suppliesbut not ostomy diagnosis
  • Labs and radiology orderedbut no indication of
    why
  • Physical exambut no mention of status amputation
  • Assessmentbut not mention of AAA size or status
  • Inconsistent documentation
  • Record indicates depression, NOS but diagnosis
    code written on encounter document is major
    depression

28
Medical Record Requirements
  • Two patient identifiers on each page Patients
    name and birth date
  • Date of Service (complete and legible)
  • Face-to-face encounter with acceptable type
    provider setting
  • Condition(s) must be documentedthey cannot be
    assumed
  • Acceptable provider signature, with credential
  • Documentation, signature and credentials must be
    legible
  • No copying/pasting/cloning
  • Diagnostic test results must be reiterated not
    copied into document

29
Potential Points of Breakdown
  • Identification
  • Do providers review past medical records?
  • Does EHR integrate across all sources?
  • Documentation
  • If providers are busy, do they record all
    coexisting conditions?
  • Do they record their thought processes?
  • Coding
  • Are coders coding all documented conditions?
  • Are coders aware that 5010 allows up to 12
    diagnosis codes?
  • Billing
  • What are the hand-offs between coding and claims
    submission?
  • Are all coded diagnoses captured on claim?
  • Functional
  • Do medical records meet stringent HCC
    requirements?
  • Reporting

30
Risk Adjustment Data Validation Audits RADV
  • National and Targeted Audits
  • Enrollees are sampled from selected MA contracts
    for the purpose of estimating payment error
    related to risk adjustment
  • CMS will select up to 201 enrollees for medical
    record review from each contract selected for a
    contract-level audit
  • CMS will calculate each contracts payment error
    based on the validation results
  • Results may be extrapolated against total
    enrollment
  • Payment recovery calculation, if applicable

31
VBP New Claims-Based Measure
  • Medicare Spending per Beneficiary
  • It is important that the cost of care be
    explicitly measured so that, in conjunction with
    other quality measures included in the Hospital
    IQR Program, CMS can recognize hospitals that are
    involved in the provision of high quality care at
    lower cost

32
CMS Intent
  • To measure hospital-specific Medicare spending
    per beneficiary, as compared to the median
    Medicare spending amount across all hospitals
    nationally
  • Will best allow hospitals to recognize where
    opportunities for improved efficiencies exist
  • 3 days prior to hospital admission through 30
    days post hospital discharge Part A Part B
  • Exclude cases involving acute to acute transfers

33
Medicare Spending Per Beneficiary
  • The data for the Medicare spending per
    beneficiary measure will be posted on Hospital
    Compare
  • CMS has finalized this measure for inclusion in
    the Hospital VBP Program beginning with the
    Fiscal Year (FY) 2015 program year.
  • CMS to make adjustments for beneficiary age and
    severity of illness (SOI)
  • SOI calculated by applying the HCC hierarchical
    condition categories which apply to the
    beneficiary during the 90 days preceding the
    Medicare spending per beneficiary episode

34
A Strategic Opportunity
  • HCCs are assigned using hospital and physician
    diagnoses from any of the following sources
  • Hospital inpatient
  • Principal diagnoses
  • Secondary diagnoses
  • Hospital outpatient
  • Physician, and
  • Clinically-trained non-physician (e.g.,
    psychologist, podiatrist)

If physician documentation is a limiting factor
under MS-DRGs, consider the impact under CMS-HCC
35
HCC Purpose
  • The ultimate purpose of the CMS-HCC model is to
    promote fair payments to MA plans that reward
    efficiency and encourage high quality care for
    the chronically ill.
  • CMS is continually conducting research on
    refining the CMS-HCC risk adjustment model. A
    major focus of this research is the incorporation
    of variables that increase the predictive
    accuracy of the CMS-HCC model for high-cost
    beneficiaries for whom the model doesnt fully
    predict expenditures.
  • Does anyone not think this will be used for ACO
    bundled payment?

36
CMS Finalizes
  • Program Changes for Medicare Advantage and
    Prescription Drug Benefit Programs for Contract
    Year 2015 (CMS-4159-F)
  • Improving payment accuracy Report and return
    identified Medicare overpayments but cannot
    submit diagnosis codes for additional payment

37
Can your CDI program assist in protecting your
hospital from fraud and payor scrutiny?
38
Thinking Outside the Box Protect your Ambulatory
Documentation
  • Traditional CDI programs focus on concurrent
    inpatient review of documentation
  • Ambulatory records are just as vulnerable to
    documentation scrutiny
  • Records that lack specific diagnoses will be
    denied for payment
  • Physicians need feedback on what documentation
    must be included for hospitals to get paid

39
CDI Mitigating Risk 3rd Party Audits
  • Perform CDI review on all cases that are
    requested for review
  • Appropriate documentation to support coding?
  • Assist with Medical Necessity review
  • Clinical expertise is critical when defending
    against auditors (RAC, OIG, 3rd party coding
    audits)
  • CDI part of your multidiscplinary team approach
    to defend your records

40
CDI at Work in the Ambulatory Setting Hospital
denied reoccurring chemotherapy charge because
only one cancer was documented
41
CDI at Work in the Ambulatory Setting Example
Hospital denied reoccurring chemotherapy charge
because only one cancer was documented
Original denial 170,000
42
CDI at Work in the Ambulatory Setting Example
Hospital denied payment for device based on lack
of documentation by surgeon
  • Dr. XXX ,
  • We have a denial from Medicare on a patient that
    received a VNS (attached). Medicare needs to have
    documentation of either A) a failed surgery prior
    to the VNS or B) documentation that the patient
    is not a good surgical candidate and therefore
    needs the VNS.
  • Based on my review, this patient is quite complex
    and would like your opinion if he falls into the
    B category. Would you please review and if you
    agree, amend your note to include that phrase? If
    this patient does not meet A or B, please let me
    know and we will accept the denial of this
    surgery.

43
CDI at Work in the Ambulatory Setting Example
Hospital denied payment for device based on lack
of documentation by surgeon
  • Dr. XXX ,
  • We have a denial from Medicare on a patient that
    received a VNS (attached). Medicare needs to have
    documentation of either A) a failed surgery prior
    to the VNS or B) documentation that the patient
    is not a good surgical candidate and therefore
    needs the VNS.
  • Based on my review, this patient is quite complex
    and would like your opinion if he falls into the
    B category. Would you please review and if you
    agree, amend your note to include that phrase? If
    this patient does not meet A or B, please let me
    know and we will accept the denial of this
    surgery.

Original denial 150,000
44
Formalize Your Denial Process
  • Best Practice
  • Ensure you have the right people at the table
  • Track results
  • Meet monthly to review progress

45
Solutions and next steps
  • Assessment Education HCC CDI Implementation

46
A Strategic Opportunity
  • HCCs are assigned using hospital and physician
    diagnoses from any of the following sources
  • Hospital inpatient
  • Principal diagnoses
  • Secondary diagnoses
  • Hospital outpatient
  • Physician, and
  • Clinically-trained non-physician (e.g.,
    psychologist, podiatrist)

If physician documentation is a limiting factor
under MS-DRGs, consider the impact under CMS-HCC
47
HCC CDI Program Benefits
  • Complete and accurate ICD-9 coding
  • Integration of ICD-10 training to assure a smooth
    transition on 10/01/your guess is as good as
    mine,
  • Appropriate coexisting condition identification
    that meet criteria for monitoring, evaluation,
    assessment, or treatment
  • Physician support of improved documentation
  • Risk Adjustment Factor alignment with patient
    acuity and severity
  • Accurate claims submission to reduce
    administrative costs associated with errors and
  • Increased readiness for dealing with potential
    RADV (Risk Adjustment Data Evaluation) audit(s)

48
Moving Forward
  • Education, analytics and workflow solution
    addressing the challenges of outpatient CDI and
    HCC coding requirements
  • Extend the current CDI workflow to support a
    centralized model of concurrent review of suspect
    HCC
  • Capture pre-billing by leveraging the Systems CDS
    department and your investment in best practices
    and tools
  • Improve revenue capture for Medicare Advantage
    Plan, Value-Based-Purchasing, and ACO initiatives

49
Summary
  • The ultimate purpose of the CMS-HCC model is to
    promote fair payments to MA plans that reward
    efficiency and encourage high quality care for
    the chronically ill.
  • CMS is continually conducting research on
    refining the CMS-HCC risk adjustment model. A
    major focus of this research is the incorporation
    of variables that increase the predictive
    accuracy of the CMS-HCC model for high-cost
    beneficiaries for whom the model doesnt fully
    predict expenditures.
  • Does anyone not think this will be used for ACO
    bundled payment?

50
Thank You!
  • Questions mel.tully_at_jathomas.com
  • Copy of Presentation doug.shaddick_at_jathomas.com
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