Welcome to the California ACDIS Chapter

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Welcome to the California ACDIS Chapter
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PEPPER Basics

• Cheryl Ericson, MS, RN, CCDS, CDIP
• Associate Director of Education, ACDIS
• CDI Education Director, HCPro
• cericson_at_hcpro.com

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Hot Topics for Organizations

• Although there are many different government
  audits Program for Evaluating Payment Patterns
  Electronic Report (PEPPER) provides an
  organization with foresight into potential
  vulnerabilities that can result in denied claims
  and recoupment
• The data is based on paid Medicare claims for a
  particular organization
• Allows STAC version is a comparison across all
  paid MS-DRGs for a particular period of time

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Hospital Vulnerability/Accountability

• An article in Healthcare Highlights quotes Asst.
  U.S. Attorney Robert Trusiak
• If hospitals receive PEPPER data information
  that their billing is way out of line, the
  government expects them to act on it. . . When
  hospitals are outliers in a risk area, they are
  expected to audit medical records and find out if
  theres a compliance problem or a reasonable
  explanation. . .
• Failure to review PEPPER data can be interpreted
  as reckless disregard or deliberate ignorance in
  a False Claims Act case
• Some Compliance Programs May Fail to Reduce the
  Risk of False Claims, Sept. 27, 2011 Wolters
  Kluwer Law Businesses

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What is PEPPER?

• A free resource released quarterly for short-term
  acute care hospitals through QualityNet
• Access is restricted to QualityNet
• Identify your facilitys administrator
• An annual version is available for other
  healthcare entities that may be direct mailed
• Long term acute care hospitals (LTAC)
• Critical access hospitals
• Inpatient psychiatric facilities
• Inpatient rehabilitation facilities

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PEPPER Basics

• Provides a quarterly analysis of
  hospital-specific Medicare inpatient claims
  (MS-DRG) that are vulnerable to improper payment
• Potential overpayments
• Potential underpayments
• Official website for information, training and
  support
• http//www.pepperresources.org/

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Definitions Page

• The MS-DRG target areas included in PEPPER are
  defined on this page and generally fall into one
  of two categories
• Coding-focused
• MS-DRG assignment
• CC/MCC capture rates
• Medical Necessity
• Short stay (one or two days) admissions
• Readmissions
• Top one day stays medical DRGs
• Top one day stays surgical DRGs

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Our Focus is Coding Targets

• Reported as percentages ()
• The numerator (top number) consists of those
  discharges prone to MS-DRG coding errors
• The denominator (bottom number) includes the
  numerator MS-DRGs as well as the MS-DRGs to which
  the claim is often reassigned
• Numerator
• Denominator

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Target Area Definition

• Are cases being inaccurately assigned to the
  higher weighted respiratory infections (MS-DRG
  177 178) compared to simple pneumonia (MS-DRG
  193, 194, 195)?
• MS-DRG 177 178
• MS-DRG 177, 178, 179 193, 194, 195

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PEPPER Interpretation

• The percentage of cases and/or volume of cases
  within each target area are the basis for
  comparison across organizations within . . .
• Medicare Administrative Contractor (MAC)
• The same state as the organization
• The United States
• The value of these comparisons will vary with the
  type of organization
• State comparison may not be as relevant to
  flagship organizations as community hospitals

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Percentile by Comparison Group
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Compare Page Data

• The volume of discharges for each target
• The percent () of cases for each target based on
  the target definition
• How each target ranks by percentile in comparison
  to other organizations
• Jurisdiction, state and the Nation
• A percentile is not the same as percentage as
  it is a ranking value not on a scale of 0 to 100
• Associated total value () of the paid claims
  (sum of payments)

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Vulnerability

• Best practice is to review a sample of claims
  whenever the organization is a high outlier or
  when there is a sudden spike in the volume of
  cases within a particular target area
• Verify the accuracy of DRG assignment
• Rebill overpayments whenever they are discovered
• Not limited to 60 days to rebill and overpayment

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PEPPER Basics

• Identification of outliers
• Comparison with other facilities in the U.S. with
  paid MS-DRGs for the same time period
• Thresholds at the 80th and 20th percentile
• High outliers are above the 80th percentile
• May result in overpayments
• Low outliers are below the 20th percentile
• May result in underpayments
• May benefit from CDI implementation or refresh

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Identifying Risk Areas at a Glance
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High Outlier Ranking Report
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Basic PEPPER Review for CDI

• A common metric of success for CDI departments is
  CC/MCC capture rate
• One of the basic reviews using PEPPER data is
  monitoring the trends associated with CC/MCC
  capture rates
• The measure of single CC or MCC can also be
  significant depending on the mission of the CDI
  department
• A high volume of cases with a single CC or MCC
  can impact mortality index and increase
  vulnerability to denials

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Basic PEPPER Review for CDI
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CC/MCC Capture for Medical DRGs
This is a positive trend and potentially shows
the positive impact of a CDI department
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CC/MCC Capture for Surgical DRGs

• This is a flat or potentially negative trend,
  but is very low compared to the medical capture
  rate
• Suggests opportunities for CDI

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Evaluating Specific Targets

• A more in-depth review of PEPPER data from a CDI
  perspective would involve analysis within
  specific coding target areas
• If multiple high outliers the sum of payment
  column can be used to prioritize target areas
  based upon amount of money at risk of recoupment

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Sum of Payments within a Target
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Sum of Payments within a Target

• To prioritize cases focus on the cost per case at
  risk rather than the total dollars at risk
• Both stroke and simple pneumonia are high
  outliers the value of each is as follows
• Stroke 308,646/35 cases 8,818 each
• Simple pneumonia 224,829/29 7,753 each

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Evaluating Specific Targets

• Can indicate opportunities of improvement
• Pneumonia can be the principal diagnosis in two
  different MS-DRGs
• Simple pneumonia cases can often be treated in
  the outpatient setting
• A high volume of simple pneumonia cases is often
  a documentation issue
• Pneumonia, unspecified (486) as the Pdx

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Sum of Payments within a Target
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Respiratory Infections
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Simple Pneumonia
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Evaluating Specific Targets

• Can indicate areas of vulnerabilities
• Perform internal monitoring of the accuracy of
  coding
• Compare to volume of TIA cases
• Is the organization a destination for stoke
  patients?

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Stroke Graph
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Not Enough Cases to Graph
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Summary

• PEPPER data can indicate possible opportunities
  or vulnerabilities
• CDI can demonstrate impact by influencing coding
  targets beyond CC/MCC capture
• Conduct internal audits to ensure
  coding/documentation accuracy when a high outlier
  and/or approaching high outlier status
• Ignorance is not a defense to false claims charges

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Thank you. Questions?