psi 90: the impact of clinical documentation improvement...

PSI 90: the Impact of Clinical Documentation Improvement and Coding on Organizational

Financial Performance Shannon Newell, RHIA, CCS, AHIMA Approve ICD-10

Trainer

Learning Objectives

At the end of this presentation, participants will be able to:

• Appreciate the impact of the PSI 90 composite on hospital reimbursement

under the Hospital Acquired Condition Reduction Program and the Hospital

Value Based Purchasing Program

• Understand PSI 90 measure specifications and risk adjustment methodology

• Explain the impact that coding and clinical documentation improvement can

have on PSI 90 performance

• Identify common coding and clinical documentation vulnerabilities for one of

the PSIs in the composite - PSI 15

• Initiate engagement of the coding and clinical documentation improvement

program in PSI 90 performance improvement efforts

CDI Program Perspective

• Inclusions

• Exclusions

• Risk adjustment

Measure Performance

Drivers

• Coding classification system

• Coding guidelines

• Documentation requirements

• Clinical definitions

Vulnerabilities

PSI Background

• Developed in 2003 by the Agency for Health Care Research & Quality

(AHRQ)

– Part of the US Department of Health & Human Services

– Research on healthcare quality, costs, outcomes, access, patient safety

5

http://www.qualityindicators.ahrq.gov/Default.aspx

PSI Background

• Indicators of quality which suggest the need for further investigation

6

PSI Overview

• Resulting PSIs

7

Available PSIs

• A weighted composite of 11 Patient Safety Indicators

• Use of a composite: – Increases statistical precision due to increased sample size

– Supports issue of competing priorities where more than one

component measure may be important

– Assists consumers select healthcare, provider allocate resources, payers

assess performance

8

AHRQ PSI #90 Measure

3 Pressure ulcer 11 Postoperative respiratory failure

6 Iatrogenic pneumothorax 12 Peri-op PE or DVT

7 CLABSI 13 Post-op sepsis

8 Post-op hip fracture 14 Post-op wound dehiscence

9 Peri-op hemorrhage/hematoma 15 Accidental puncture/laceration

10 Postop physiologic & metabolic derangement

PSI 90 Overview

• Payer assessment of provider performance

• CMS adoption into the Inpatient Quality Reporting Program (IQRP) – Public reporting on CMS Hospital Compare

9

PSI Payer Utilization

• CMS inclusion in two pay for performance (P4P) programs

– FY 2013 – Hospital Value Based Purchasing Program (HVBP)

– FY 2015 – Hospital Acquired Condition Reduction Program (HACRP)

• Financial impact:

10

PSI 90 & CMS P4P

HRRP = Hospital Readmission Reduction Program

• PSI 90 currently assigned to the Outcomes Domain

• FY 2017 domain revisions - PSI 90 will move to Safety Domain

11

10%

25%

40%

25%

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

Cinical Process of Care

Patient Experience of Care

Outcomes

Efficiency

HVBP Domains FY 2013 - 2016

FY 2016 FY 2015 FY 2014 FY 2013

HVBP Domains & Weights

12

HVBP Domains & Weights (cont)

FY 2016IPPS Proposed Rule - in FY2018: 1) Eliminate subdomain “Clinical Care – Process” 2) Eliminate all process measures except PC-01 which will move to “Safety Domain”

30%

20%

25%

25%

25%

25%

25%

25%

0% 5% 10% 15% 20% 25% 30% 35%

Clinical Care

Safety

Efficiency & Cost Reduction

Outcome & Care Coordination

HVBP Domains FY 2017

FY 2018 (Proposed) FY 2017 (Finalized)

FY 2015

Outcomes Domain

FY 2017

Safety Domain

13

Measure (3> measures for Domain Score)

PSI 90

CLABSI

CAUTI

SSI – Colon, Abd Hysterectomy

C. difficile

MRSA

Measure (2> measures for Domain Score)

PSI 90

MORT-30-AMI

MORT-30-HF

MORT-30-PN

CLABSI

FY 2018 –

Add PC-1 Elective Delivery

HVBP Domains & Weights (cont)

• PSI 90 comprises Domain I

• Note the decline in Domain I weight in upcoming years

14

35%

25%

15%

65%

75%

85%

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

FY 2015

FY 2016

FY 2018

HACRP

HAI (DII) PSI 90 (D1)

HACRP Domains & Weights

• Compares performance scores

with point system

– Other hospitals (achievement)

– Itself (improvement)

HACRP

• Ranks performance against other

hospitals – scored using deciles

HVBP

15

CMS P4P Variances Scoring

• HACRP Performance Period

• HVBP Performance Periods

16

Baseline Period Performance Period

FY 2015 10/15/2010 - 06/30/2011 10/15/2012 – 06/30/2013

FY 2016 10/15/2010 – 06/30/2011 10/15/2012 – 06/30/2014

FY 2017 10/01/2010 – 06/30/2012 10/01/2013 – 06/30/2015

FY 2018* 07/01/2010 – 06/30/2012 07/01/2014 – 06/30/2016

FY 2019 07/01/2011 – 06/30/2013 07/01/2015 – 06/30/2017

FY 2020 07/01/2012 – 06/30/2014 07/01/2016 – 06/30/2018

Performance Period

FY 2015 07/01/2011 – 06/30/2013

FY 2016 07/01/2012 – 06/30/2014

FY 2017* July 1, 2013 – June 30, 2015

CMS P4P Variances Time Periods

*FY2016IPPS Proposed Rule

17

• Different versions

• Impact

– Measure specifications

– Risk adjustment variables

– Risk adjustment coefficients

– Performance comparisons

• Across programs

• Across years

– Composite weighting

• Key variances

– # of diagnoses used

– PSI composite weighting

CMS P4P Variances PSI Versions

• Different versions impact how PSI performance is weighted

18

2.3

%

7.1

%

6.5

%

0.1

%

25

.8%

7.4

%

1.7

%

49

.2%

-10%

0%

10%

20%

30%

40%

50%

3 6 7 8 12 13 14 15

PSI Composite Weight

HACRP HVBP

CMS P4P Variances PSI Versions (cont)

• Excludes 3 of the PSIs in the AHRQ PSI 90 Composite*

– 9 Peri-operative hemorrhage/hematoma

– 10 Post-op physiologic & metabolic derangement

– 11 Post-op respiratory failure

• Refines statistical methodologies (“smoothed rate”) to account for

Medicare population characteristics

19

CMS PSI #90 Measure

3 Pressure ulcer 12 Peri-op PE or DVT

6 Iatrogenic pneumothorax 13 Post-op sepsis

7 CLABSI 14 Post-op wound dehiscence

8 Post-op hip fracture 15 Accidental puncture/laceration

CMS Modifications to AHRQ PSI 90

*PSI 90 is currently undergoing NQF maintenance review

• AHRQ

– Healthcare Cost Utilization Program (HCUP) databases

– State data

– All payer population

• CMS

– Final action paid claims from the inpatient Health Accounts Joint

Information (HAJI) files

– Medicare part A claims data

– Traditional Medicare population

• Includes claims submitted for discharges with dates in the cited discharge

periods

20

Data Sources

The Impact of Documentation & Coding

• Code assignment has a significant impact on claims based measures

• Code assignment has some impact of some chart abstracted measures

22

The Impact of Code Assignment

• Reimbursement

• Reputation

• Performance Improvement

23

MS-DRG 690 Urinary tract infection wo complication

MS-DRG 871 Sepsis major complication

UTI Bacteremia Hypotension Hypoxemia Cachexia

6 day LOS Expired

Sepsis due to UTI Septic shock

6 day LOS Expired

1 2

Impact- MSDRGs

24

MS-DRG 690 Urinary tract infection wo complication

SOI score - 3 ROM score - 3

MS-DRG 871 Sepsis w major complication

SOI score – 4 ROM score - 4

UTI Bacteremia Hypotension Hypoxemia Cachexia

6 day LOS Expired

Sepsis due to UTI Septic shock Resp failure, acute Malnutrition

6 day LOS Expired

2 1

Impact – APR-DRGs Severity of Illness (SOI), Risk of Mortality (ROM)

• Documentation and code impact: inclusions, exclusions, risk adjustment

25

Measure Impact PSI Example

Includes discharge PSI 3 Pressure Ulcers

Pressure ulcer not present on admission unstageable

Excludes discharge PSI 3 Pressure Ulcers

Any pressure ulcer present on admission

Excludes discharge PSI 7 Central line associated blood stream infections

History of a malignant neoplasm

Excludes discharge PSI 8 Post-op hip fracture

“Pathologic” fracture

Excludes discharge PSI 13

Post-op sepsis

Admission type other than elective

Risk adjustment PSI 15

Accidental puncture/ laceration

“Obesity”, “Pulmonary Hypertension”, “CKD”

Impact- PSI 90

Measure Structure

• Technical Specifications

27

PSI 15 # of Patients with Pressure Ulcer / # Patients in Population

Measure Structure

• PSI 15 – Accidental Puncture / Laceration

28

Numerator = inclusion

Numerator – “Outcome of Interest”

• PSI 15 – Accidental Puncture / Laceration

29

Numerator = inclusion

• Inclusions

Denominator – Population “At Risk”

• PSI 15 – Accidental Puncture / Laceration

30

Numerator = inclusion

• Inclusions

Denominator – Exclusions

Exclusions: • Improve accurate

capture of intended population

• Enhance face validity with clinicians

31

Risk Adjustment Methodology

32

Risk Adjustment Methodology (cont)

• 25 comorbid categories

■ ICD code mapping

■ Same definitions

■ Varied application

■ Varied risk adjustment

impact

■ Must be POA

■ Denominator capture counts

• AHRQ HCUP Comorbidity

Software is used to create the

risk adjustment coefficients

33

Numerator = inclusion

Risk Adjustment Methodology (cont)

• ICD-9-CM code mapping

■ Volume of codes: 1 code (HIV) 255 codes (Lymph)

■ In general: chronic conditions, low specificity (e.g. “CHF”, “anemia”)

34

Numerator = inclusion

Risk Adjustment Methodology (cont)

• Impact can be positive or negative

35

Numerator = inclusion

PSI #3

61%

20%

16%

4%

0%

10%

20%

30%

40%

50%

60%

70%

WGHTLOSS OBESE PERIVASC RENLFAIL

PSI #15

Risk Adjustment Methodology (cont)

36

• Inclusions

Discharge

Discharge

Discharge

Eligible Discharges (Denominator) (Population at risk)

Outcomes of Interest

(Numerator) Risk Adjustment

(Comorbid Conditions)

Summary

37

Summary (cont)

Coding and Documentation Vulnerabilities

39

Numerator = inclusion

PSI #3

Code Review

Coding Classification System: Index and Tabular must be used together

• Coding classification system provides all available codes

• Coding guideline hierarchy

– Classification system

– Official Coding Guidelines (OCG)

– AHA Coding Clinics

• Includes accidental perforation by catheter or other instrument during a

procedure on blood vessel, nerve, organ

• Excludes iatrogenic pneumothorax, dural tears, puncture or laceration by

implanted device intentionally left in operation wound, others

Inclusion – Assignment of Code 998.2 Classification System

40

Inclusion – Assignment of Code 998.2 OCG – Additional Diagnoses

41

Inclusion – Assignment of Code 998.2 OCG - Complications

42 Official Coding Guidelines – Section I-B, I-C

• “Complication” – assign 998.2

Inclusion – Assignment of Code 998.2 AHA Coding Clinic – “Complications”

43

• The physician does not need to document the word “complication”

Inclusion – Assignment of Code 998.2 AHA Coding Clinic – “Tear”

44

Inclusion – Assignment of Code 998.2 AHA Coding Clinic – “Tear”

45

• Dural tears are always coded

– “Always clinically significant due to the potential for CSF leakage”

– Secondary diagnoses reporting criteria – additional monitoring

– Code assignment is NOT 998.2. (Not included in PSI 15)

• “Tear” controlled with hemopad

• Query: Inherent or complication

Inclusion – Assignment of Code 998.2 AHA Coding Clinic – “Tear”

46

• “Serosal injury” with repair in setting of mass adhered at GE junction

• Query: Incidental or complication

Inclusion – Assignment of Code 998.2 AHA Coding Clinic – “Injury”

47

Inclusion – Assignment of Code 998.2 Case by Case Interpretation

48

Procedure Op Note Documentation

Lap converted to open

appendectomy and repair of

bladder injury

“The appendix was ultimately identified and dissected away

from these structures. In the process of doing this and

identifying the abscessed cavity, there was a tremendous

amount of necrotic material overlying the bladder. In debriding

this material, the bladder was entered. It appeared that the

bladder wall was also involved, and a portion of the bladder

wall appeared nonviable. At this point Urology was consulted

for assistance in repairing the bladder.

Lap gastric band removal,

intraoperative endoscopy repair

“The endoscope was then removed and at this point we noticed

a small 1 cm laceration in the inferior medical portion of the

spleen that was actively bleeding; pressure was held on the

site for 10 minutes. An additional Evicel was applied over the

Surgicel until the area was hemostatic.”

Right ankle arthrodesis, right

distal tib-fib arthrodesis, removal

of hardware from right fibula,

removal of hardware right tibia

“During this section due to significant amount of scar tissue her

peroneous brevis tendon was entrapped in scar tissue and

ruptured while it was being released.” “Prior to closure of skin

and subcutaneous tissues we did repair the peroneous brevis

tendon, which was quite easy to accomplish.”

Inclusion – Assignment of Code 998.2 UHC PSI 15 Consensus Document

49

Terminology

Not Complication Complication

• Required • Inherent • Integral • Routinely expected

• Complication • Inadvertent • Unintended • Iatrogenic • Unexpected

• Template – post-op note complication field

• Report so it can be coded, reported, and evaluated

for performance improvement

• Physician documentation

– Non-accidental: inherent/integral/intended, reasons for

– Complication

50

Inclusion – Assignment of Code 998.2 UHC PSI 15 Consensus Document (cont)

• CDS / Coders to query if unclear

– Procedure note terminology / without description of circumstances

– Post op / procedure note documentation conflicts with other documentation

in the medical record

– Indications of a reportable event

• Reportable if required: clinical evaluation, treatment, procedure, length

of stay, increased nursing care or monitoring

• Examples:

– Repair

– Follow-up

– Blood transfusion

– Return to OR

– Consult

– Resulted in damage to / loss of organ / death

Inclusion – Assignment of Code 998.2 Bulletin ACS May, 2014

51

Inclusion – Sequencing of Code 998.2 OCG – Principal Diagnosis Sequencing

52

53

Inclusion – Sequencing of Code 998.2 OCG – Principal Diagnosis Sequencing

Inclusion – Assignment of E Codes OCG – E Code Assignment

54

Risk Adjustment Diagnoses OCG – Additional Diagnoses

55

• Any healthcare provider

– Physicians

– Any qualified healthcare practioner legally accountable for establishing

the patient’s diagnosis

• Current encounter

– Entire medical record

• When conflict across providers, query attending physician

– Conflict? “Bacteremia” “Sepsis” – Conflict? Attending physician did not document

56

Source: CMS Medicare Learning Network (MLN) Matters -SE 1121

Risk Adjustment Diagnoses OCG – Documentation Sources

• Documented “at the time of discharge”

• Uncertain Diagnosis Exceptions

– HIV

– Influenza due to some viruses – avian, novel, H1N1, influenza A

57

Risk Adjustment Diagnoses OCG – Uncertain Diagnoses

• Risk Adjustment does not count comorbid conditions unless POA

58

Risk Adjustment Diagnoses OCG – Present on Admission

• “Chronic conditions such as but not limited to HTN, Parkinson’s disease,

COPD, & diabetes mellitus are chronic systemic diseases that ordinarily

should be coded even in the absence of documented intervention or further

evaluation.”

59

Risk Adjustment Diagnoses AHA Coding Clinic – Chronic Conditions

• AHIMA and ACDIS Query Practice Brief 2013

60

Risk Adjustment Diagnoses Query Practice Brief – Clinical Validation

• 4th highest positive impact

• 25 codes

Risk Adjustment Diagnoses CC: RENLFAIL – Key Concepts

61

Numerator = inclusion

61%

20% 16%

4%

0%

10%

20%

30%

40%

50%

60%

70%

WGHTLOSS OBESE PERIVASC RENLFAIL

PSI #15

Key Concepts

• CKD

• “Renal failure”

• Kidney transplant status

• Renal dialysis status

• Highest impact

• 18 codes

Risk Adjustment Diagnoses CC: WGHTLOSS – Key Concepts

62

Numerator = inclusion

61%

20% 16%

4%

0%

10%

20%

30%

40%

50%

60%

70%

WGHTLOSS OBESE PERIVASC RENLFAIL

PSI #15

Key Concepts

• Malnutrition

• Underweight

• Loss of weight

Adults: BMI < 18.5 Children: < 5th %ile

Risk Adjustment - WGHTLOSS Clinical Definitions – Underweight

63

www.cdc.gov/healthyweight/assessing

Risk Adjustment - WGHTLOSS Classification System - Malnutrition

64

• Includes all codes

65

• Includes

─ “CKD <stage”, “chronic renal insufficiency, “Renal failure” ─ Does not include “acute renal failure”

Risk Adjustment Diagnoses - RENLFAIL Classification System - CKD

66

• Does not include “renal insufficiency” unless documented as “chronic”

• Does not include ‘acute renal insufficiency”

Risk Adjustment Diagnoses - RENLFAIL Classification System – Renal Insufficiency

67

Numerator = inclusion

PSI #3

Audit Checklist

CDI Program Engagement

69

• Definition of CDI Program

An organizational system chartered to improve capture of clinical

documentation and ICD code assignment

• Common Organizational Objectives

■ Accurate, optimal reimbursement for provided services

■ Minimal delays in billing due to post-discharge documentation queries

■ Minimal re-bills associated with post-discharge documentation and

associated ICD-code revisions

■ Reduction of denials by payers and other external review organizations

■ Accurate, optimal quality profiles for claims based outcomes

• CDI Program

■ Coding team and processes

■ Clinical documentation specialist team and processes

■ Performance management

CDI Program Overview

70

What Measures? Risk Adjustment?

• Numerous methodologies for quality measures • Each system has its own methodologies • Lack of agreement among the national hospital rating systems • Example: Only 10% of hospitals rated as a high performer by one rating

system were rated as a high performer by other leading national hospital rating systems

http://m.content.healthaffairs.org/content/34/3/423.abstract?sid=6c0faf3e-5fc0-45f1-80ba-5e3c39982828

71

• Risk adjustment will be optimized for PSI 7 (CLABSI) with capture of one diagnosis from each of the following comorbid categories

19%

16%

13% 13%

7% 7% 6%

5% 5% 4%

3%

0%

0%

5%

10%

15%

20%

25%

WGHTLOSS PARA BLDLOSS DRUG OBESE NEURO ANEMDEF RENLFAIL CHF LIVER ARTH VALVE

PSI #7

CDI and CMS P4P

■ Systematic capture of “underweight”

■ Systematic capture of kidney disease acuity and stage

72

E.H.R. Refinement

Falcon Consulting

• Success under CMS P4P requires clear organizational priorities, a data

driven focus, and strengthening of the documentation infrastructure

73

CDI Program Evolution

Coding & Query Process

Provider Education

Performance Management

Documentation Infrastructure

CDI Program

• Develop CDI team quality lead role

• Identify organizational priorities

• Educate the CDI team on measure drivers

• Identify (and validate) data quality vulnerabilities

• Develop and implement actions to strengthen performance – CDI Team review processes

– Pre-bill validation review

– Provider education

– E.H.R. refinements

• Monitor performance improvement – Refine CDI Program Performance Metrics

– Participate on quality teams

Engagement Checklist

74

• Table 3 - PSI performance breakout

– “Better performance” = Smoothed Rate < National Risk Adjusted Rate

– Consider composite weight, volumes

– Annual ranking by decile continual improvement

HACRP Hospital Specific Report

75

High Leverage Opportunities Inclusions & Exclusions

76

Inclusion/Exclusion Impacting 2> PSIs

PSI

3 6 7 8 12 13 14 15

POA Status

Length of Stay (dates)

Cancer Dx (includes personal hx)

Immunocompromised State

Procedure Dates

E Codes

Point of Origin* * * * *

* Impacts risk adjustment per Parameter Estimates

Summary

• Documentation and code assignment impact claims based measure

performance through accurate and optimal inclusion, exclusion, and risk

adjustment of discharges

• CMS P4P initiatives expand the financial impact of assigned codes

• Evolution of today’s CDI programs is required to address these new challenges

Thank You – Questions?