building a successful outpatient clinical...
TRANSCRIPT
Building a Successful Outpatient Clinical Documentation Integrity Department
2016 A A PC R EGI ONAL CON FER EN CE – AT LA N TIC C I T YOC TOBER 6 TH 2016
PRESENTERSDonna Beaulieu, CRC, C-CDIS, CPC, CPMA, CPC-I, CEDC, CEMC, CFPC, CRC, CCP-P, CRPHasan Zaidi, MPH, CPC, CRC, CEDC, CSPPM
Presentation Agenda
Shift Towards Fee for Value◦ Overview of new Payment Methodologies
Outpatient Clinical Documentation Integrity (CDI)◦ Purpose
◦ Process
◦ Outcomes
Risk Adjustment Overview◦ Hierarchical Condition Category Codes
◦ Case Studies
Questions/Feedback Session
Change is inevitable.
“In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer
exists.”
—Eric Hoffer, American philosopher and author of The True Believer: Thoughts on the Nature of Mass Movements
Shift Towards Fee for Value: Why?
Outcomes are not always achieved◦ 2000 Institute of Medicine Report, “To Err is Human”
Cost is higher than is sustainable◦ Escalating costs for the last 25 years
Unnecessary Costs◦ 1/3 of what we spend money on in healthcare is unnecessary
◦ Fear of failing to find something
◦ Defensive medicine
◦ Lack of interoperability between EHR
◦ Other reasons
Shift Towards Fee for Value
Increase provider adherence and compliance with evidence based practices
Increase patient adherence and compliance with care plans
Reduce hospitalizations
Reduce length of stay
Avoid unnecessary readmissions
Avoid redundant tests and studies
Improve utilization management for drug therapies and device therapies
Fee for Service Fee for ValueFee for Service Fee for Value
Service is rendered, payment is received by payer
Service is rendered, payment is dependent on:
• Meeting quality measures• Participating in fee for value payment
models• Effective care coordination of
patients via primary care medical home
Quantity drives revenue (high volume = high reimbursement)
Beginning in 2019* payments will be linked to quality and value
• Merit-based Incentive Payment System
• Alternative Payment Model*based on performance year of 2017
MACRA? MIPS? APM?
What we know?
Only one-fifth of physicians are “familiar” with new Quality Program
CMS Response: “Pick you Pace”
Final rules implementing MACRA are expected by November 2016
*The Physicians Foundation 2016 Physician Survey
Physicians Familiar With MACRA*
Medicare Access and CHIP Reauthorization Act (MACRA)
FEE FOR SERVICE FEE FOR VALUE
Dissolves Sustainable Growth Rate (SGR)
Creates Quality Payment Program
Two tracks:
Merit-based Incentive Payment System (MIPS)
Alternative Payment Models (APMs)
Payment methodology = proper clinical documentation & coding
Quality Track #1: MIPSStreamlines multiple independent programs in to ONE
The Physician Quality Reporting System (PQRS): focus on quality measurement and improvement
The Medicare Electronic Health Record (EHR) Incentive Program: focus on meaningful use to promote sharing of care information
The Value Modifier (VM) Program: focus on resource use
QualityAdvancing
Care Information
Clinical Practice
ImprovementActivities
Resource Use
(Cost)
50% 25% 10% 15%
MIPS Components DefinedQuality
Selection of outcome measures, population measures, PQRS measures
Advancing Care Information
Utilization of Electronic Health Record (e-prescribing, HIX, PHI, etc.)
Resource Use
Comparison of resources used to treat similar care episodes and clinical conditions groups across medical practices
Clinical Practice Improvement Activities
Patient Centered Medical Home, care coordination, shared decision making, safety checklists, expanding practice access
MIPS – Payment ChangesFor the first time in history, payment amounts for services providers deliver to Medicare beneficiaries will vary among the providers!
Some providers may potentially receive more than 30 percent greater payment amount than other providers based on higher performance
Payment adjustment type: positive, negative, or neutral
Performance Year PaymentAdjustment Year
Adjustment %
2017 2019 +/- 4%
2018 2020 +/- 5%
2019 2021 +/- 7%
2020 and after 2022 and onwards +/- 9%
Participation in MIPSParticipation in MIPS by:
o Individual*
o Group: Taxpayer identification number* (TIN)
MIPS eligible clinicians
*Year 1 & 2: Physicians, PAs, NPs, Clinical nurse specialists, Certified registered nurse anesthetists
*Year 3: Physical or occupational therapists, Speech-language pathologists, Audiologists, Nurse midwives, Clinical social workers, Clinical psychologists, Dietitians / Nutritional profession
Quality Track #2: APMNew approaches to paying for medical care through Medicare that incentivize quality and value!
Proposed Rules:
CMS Innovation Center model (under section 1115A, other than a Health Care Innovation Award)
MSSP (Medicare Shared Savings Program)
Demonstration under the Health Care Quality Demonstration Program
Demonstration required by federal law
CMS Innovation Center model
Quality Track #2: APMNew approaches to paying for medical care through Medicare that incentivize quality and value!
APM Checklist:
Use of quality measures comparable to measures under MIPS
Use of a certified electronic health record (EHR) technology
Assumes more than a “nominal financial risk” OR is a medical home expanded under the CMMI.
APM Qualifying Criteria Following criteria must be met in order to participate as an Advance APM:
Use of Certified electronic health record technology (CEHRT) 50% usage of CHERT by eligible clinicians
Requires MIPS Comparable Quality Measures At least One Outcome measure
No minimum requirement on quality measures
Requires APM Entities to Bear More than Nominal Financial Risk
APM: RISK Bearing TRACKTo qualify for APM, provider participants should be able to bear a certain amount of financial risk:
◦ Total risk, or the maximum amount of losses possible under the advanced APM, which must be at least 4 percent of the APM spending target
◦ Marginal risk, or the percentage of spending above the advanced APM benchmark (or target price for bundles) for which the advanced APM entity is responsible (i.e., sharing rate), which must be at least 30 percent
◦ Minimum loss rate—the amount by which spending can exceed the APM benchmark (or bundle target price) before the advanced APM entity has responsibility for losses—which must be no greater than 4 percent
APM Outlook:CMS notes in the fact sheet for its proposed rule regarding the Quality
Payment Program:
“For years 2019 through 2024, a clinician who meets the law’s standards for Advanced APM participation is excluded from MIPS adjustments and
receives a 5 percent Medicare Part B incentive payment.
For years 2026 and later, a clinician who meets these standards is excluded from MIPS adjustments and receives a higher fee schedule
update than those clinicians who do not significantly participate in an Advanced APM.”
APM Payment AdjustmentsFor years 2019 through 2024: 5 percent Medicare Part B incentive payment.
For years 2026 and later: Higher fee schedule update than those clinicians who do not significantly participate in an Advanced APM
What are our options*?4 approaches as we step in to 2017:
1. Test the Quality Payment Program
2. Participate for part of the calendar year
3. Participate for the full calendar year
4. Participate in an Advanced Alternative Payment Model in 2017
*As of September 2016
Need for outpatient CDI?
Difference between DRG Optimization &Hierarchical Condition Category Codes (HCC)?
DRG OPTIMIZATION: Unfortunate result for some hospitals as they transitioned towards Clinical Documentation Improvement (CDI) in the 1990s. Hospitals began to up-code/falsify diagnosis-related groups (DRGs) by “gaming” the system to maximize DRG payments.
HIERARCHICAL CONDITION CATEGORY (HCCs):
Helps capture accurate patient acuity in the outpatient setting and have associated risk value for diagnosis codes (Risk Adjustment Factor – RAF).
Unlike DRG Optimization (where optimization teams reviewed and coded DRGs – queries to providers), documentation and coding is provider driven and leading queries are not part of the outpatient workflow.
Setting the context: Case Study
Patient Name: Ms. Jones
Chief Compliant: A 85 year old white female, symptoms of UTI.
HPI: Patient is tired, less energy and poor appetite and had a heart attack (MI) 1 year ago. Patient has mild malnutrition, is frail and has lost 30 lbs in the past 6 months. Urinalysis performed which shows white cells, leukocyte esterase, and microalbuminuria. Serum creatinine is 1.8. Patient has been complaining of urinary discomfort, weakness, and has had dry and itchy skin for the past 6 months. Alcohol dependence, in remission.
Past Medical History: Urinary Artificial Opening (Active), Stable diabetes mellitus (DM), chronic kidney disease (CKD) exacerbated by diabetes, stable BKA, stable history of MI, UTI w/ serum creatinine 2.2 six months ago. Lab findings revealed CKD stage 4.
Plan: Glucophage 500 mg b.i.d. for DM. Cipro for UTI. Ensure supplements for malnutrition. Return to Clinic in 3 months. Referral to nephrologist for CKD4
Setting the context: Case StudyHCC Impact: Capturing more complete and accurate patient picture
Documented ConditionsICD10-CM
CodeCMS HCC Category
CMS Risk Score
Demographic Score Total RAF ScoreExpected Payment
Diabetes, Type II, Uncomplicated E11.9 19 0.1620.677 0.839* $671.20
UTI N39.0 - 0
Diabetes Mellitus w/ Renal
ManifestationsE11.29 18
0.508
0.677 4.031* $3224.80
UTI N39.0 - 0
Diabetic Nephropathy E11.21141
Trumped by CKD Stage 4
CKD Stage 4 N18.4 137 0.244
Mild Degree Malnutrition E44.1 21 0.856
Artificial opening, status code Z93.9 188 0.651
BKA Status Z89.519 189 0.675
Alcohol Dependence, in remission F10.21 55 0.420
Scenario 2: Accurate capture of patient’s true acuity and Risk Adjustment Scores:
Scenario 1: What we normally see:
*HCC codes/values are updated every year requiring constant changes to disease sets and patient acuity capture.
Discussed later in our presentation…
Why Documenting & Coding accurate patient acuity matters?
• WHAT: Assess, identify and report gaps in specific patient disease sets
• HOW: Targeted Retrospective Audits
ENSURE COMPLETE & ACCURATE
DOCUMENTATION
• WHAT: Accurately reflect the cost component of patient’s care
• HOW: HCC/Risk Adjustment Factor Capture
REFLECT COST OF CARE BY CAPTURING TRUE PATIENT
ACUITY
• WHAT: Holistic capture of quality measures
• HOW: HEDIS Quality Measures for Medicare Advantage Plans
IMPROVE QUALITY REPORTING
• WHAT: Ensure documentation matches services billed
• HOW: Targeted Retrospective Audits
REVENUE INTEGRITY
Provider Education
Audit Feedback
Patient Acuity
ENSURE COMPLETE & ACCURATE DOCUMENTATION
PURPOSE: Assess, identify and report gaps in specific patient disease sets
PROCESS:
o IDENTIFY: Utilize past claims data to generate audit sample based on patient acuity (prior month’s data)
o CONDUCT: Perform retrospective audits for each provider (50% of time spent)o REVIEW: Utilize coding guidelines to determine associated links within documentation.
o QUERY: Query as appropriate to seek clarity in provider’s documentation
DELIVERABLES:
Retrospective Chart Review Findings
Service Line Analysis (Top Diagnosis & CPT codes)
METRICS FOR SUCCESS:
- % of Clinical Notes Closed within 24 hours
- Provider Query & Response Rate
REFLECT COST OF CARE BY CAPTURING TRUE PATIENT ACUITY
PURPOSE: Accurately reflect the cost component of patient’s care
PROCESS:
o ANALYZE: Review clinical documentation to ensure documentation translates in to appropriate diagnosis codes.
o COMPARE: Review CMS published risk scores/categories to drive highest level of specificity in diagnosis codes.
o QUERY: As appropriate, query the provider to determine causal relationships between diagnosis codes. o GENERATE: Prepare pre/post assessment of provider’s documentation to reflect accurate patient acuity.
DELIVERABLES (personalized provider profile):
ICD10 Risk Adjustment Specialty Crosswalk
Risk Adjustment Patient Examples (provider specific)
METRICS FOR SUCCESS:
- % of Non-RAF Codes
- # of RA Categories Utilized
IMPROVE QUALITY REPORTING
PURPOSE: Holistic capture of quality measures
PROCESS:
o REVIEW: Use 2017 HEDIS measures to ensure appropriate capture of quality measures for Commercial, Medicare and Medicaid payers.
o ASSESS: Review provider documentation to identify gaps in quality measures capture.
o PARTNER: Collaborate with care teams to provide consistent feedback on missed opportunities. o BUILD: Work with appropriate teams to load updated quality measure codes in EeMR. Assist with template
updates, as needed.
DELIVERABLES (personalized provider profile):
Category II codes capture by each provider (pre and post assessment)
Specialty Category II codes capture
METRICS FOR SUCCESS:
- % of Quality Measures Capture for Key Indicators (BMI, Diabetes Management, Blood Pressure, Lipid Management, Preventive Screening, etc.)
- # of Template Updates (coding/documentation related)
REVENUE INTEGRITY
PURPOSE: Ensure documentation matches services billed
PROCESS:
o CAPTURE: Ensure all services are documented in the medical record (including ancillary services).
o VALIDATE: Confirm procedures support medical necessity and key documentation elements.
o QUERY: As appropriate, query the provider to determine causal relationships, seek clinical clarifications and medical decision making to support services billed.
o COMMUNICATE: Share overall documentation/coding findings to providers via faculty meeting or 1 on 1session.
DELIVERABLES (personalized provider profile):
FPSC Bell Curve Analysis
Procedure Specific Playbooks (drive standardization in documentation)
METRICS FOR SUCCESS:
- # of Encounters
- wRVUs by Providers
- Medical Necessity Denials
Patient Panel Identification
Audit SheetProvider Patient Name MRN Date of Service Charge
Amount
ICD 10 Billed ICD 10 Audit Result CPT Billed CPT Audit Result Specificity in Documentation
Present? (Y/N)
Specificity in Diagnosis
Present? (Y/N)
Overall Audit Result
(CPT) - Over coded, under
coded, no change
Documentation Comments
(Problem list, medication list, A&P, etc.)
Standard Query ProcessRequest for Clarification-Associated Conditions
Dear Physician/PA/NP: ____________________________________________________________________ or other responsible provider:
For accurate coding and severity-of-illness compilation, this query is directed to you. When responding to this query, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular answer is desired or expected.
The pt has documented –
A cause-and-effect relationship between diagnoses may not be assumed and must be explicitly documented. Please document the cause-and-effect relationship, if any, between these conditions.
Diagnosis Specificity
Benchmarking with peers
Risk Adjustment Overview
Objectives
◦Discuss the meaning of risk adjustment
◦Discuss the meaning of hierarchical condition categories (HCC)
◦Review documentation requirements for accurate HCC capture
◦Review case studies
Risk Adjustment Factor (RAF) A “risk adjustment score” is determined by using a combination of demographic information in tandem with disease information as a predictive factor for calculating expected future health costs for members and beneficiaries.
The sicker the patient, the higher the RAF score.
Calculating the RAF ScoreTotal score of all relative factors related to one patient
for a total calendar year are derived from the combination of two scores:
Age & either community-based or institution-based
Medicaid disability and interaction with age and gender
Diagnoses reported on claims submitted for face-to-face encounters determines HCC categories
Interaction between certain HCC categories
Interaction between disease categories and disability status
Purpose of Risk Adjustment ScoresMedicare Care Advantage PlansCurrently active
Managed Care plans with “shared savings” incentivesCurrently active
Part of the Total Performance Score for Value
Based purchasingFuture state
Hierarchical Condition Categories (HCC)
Developed by CMS for Medicare Advantage plans
CMS Rx HCC model for Medicare Part D
2014 Model includes 79 condition categories with 25 “short-name” categories
Developed by the Dept. of Health & Human Services for commercial payors.
Used for a predictive factor of future healthcare costs, including medications and any necessary supplies.
CMS HCC HHS HCC
Application and Calculation of HCCsMedicare Advantage plans use to calculate “per member
per month” cost
Current year data as a predictive year risk
Diagnoses collected from claims submitted within a year◦ Diagnoses only collected from face-to-face encounters
◦ Eligible Providers are: Physicians
Nurse Practitioners
Physician Assistants
CRNA
Therapists
Psychologists
Podiatrists
HCC Breakdown
70,000+ ICD-CM codes included in…
189 hierarchical condition categories within…
79 HCC categories within…
25 “short name categories”
“Short Name Categories”
Infection Metabolic LiverNeoplasm Diabetes
Gastro-intestinal
Spinal
Vascular
Injury
Musculo-skeletal
Neurologic
Lung
Compli-cations
Blood
Arrest
Eye
Transplant
SubstanceAbuse
Heart
Kidney
Openings
Psychiatric
Cerebo-vascular
Skin
Ampu-tations
How HCCs are assessedIn risk adjustment models, certain diagnosis codes carry a “risk adjustment value” (RAF)
This is a cross between DRGs for facility coding and RVUs for professional coding
The more severe or complex a diagnosis within an HCC category, the higher the value.
If two or more conditions are coded from the same category, the diagnosis that is more sever will the trump any others from the same category
Documentation & RAF
No Coded Conditions
RAF Some Conditions Coded RAF All Conditions Coded (based on certified risk
adjustment coder)
RAF
76 y.o. female 0.437 76 y.o. female 0.437 76 y.o. female 0.437
Medicaid eligible 0.151 Medicaid eligible 0.151 Medicaid eligible 0.151
DM not coded 0.00 DM II no complications 0.118 DM II w/vascular manifestations
0.368
Vascular disease not coded
0.00 Vascular disease, no complications
0.299 Vascular disease w/complications
0.410
CHF not coded 0.00 CHF not documented 0.00 CHF coded 0.368
No interaction 0.00 No interaction 0.00 + Disease interaction “bonus” RAF (DM + CHF)
0.182
Patient Total RAF 0.588 Patient Total RAF 1.005 Total Patient RAF 1.916
PMPM $412 PMPM $704 PMPM $1341
Yearly Reserve $4,944 Yearly Reserve $8448 Yearly Reserve $16092
* All values are based on CMS 2014 Model 22 with hypothetical baselines
Variable Community Institution
Female
0-35 Years 0.197 1.169
35-44 Years 0.205 0.949
45-54 Years 0.263 0.915
55-59 Years 0.326 0.981
60-64 Years 0.392 0.986
65-69 Years 0.288 1.237
70-74 Years 0.348 1.145
75-79 Years 0.437 1.033
80-84 Years 0.539 0.922
85-89 Years 0.677 0.836
90-94 Years 0.815 0.705
95 Years and older 0.840 0.533
Table 1. 2014 CMS HCC Model Relative Factors for Community & Institutional
Medicaid and Originally Disabled Interactions with Age and Sex
Condition Community Institutional
Medicaid Female Aged 0.151 0.067
Medicaid Female Disabled 0.085 0.067
Originally Disabled Female 0.177 0.067
Additional Considerations when calculating Risk Adjustment Factors
Disease Coefficients Description Label Community Institutional
HCC1 HIV/AIDS 0.470 1.904
HCC2 Septicemia, Sepsis, SIRS 0.535 0.575
HCC6 Opportunistic Infections 0.440 0.344
HCC8 Metastatic Cancer/Acute Leukemia 2.484 1.203
HCC9 Lung & Other Severe Cancers 0.973 0.674
HCC10 Lymphoma & Other Cancers 0.672 0.412
HCC11 Colorectal, Bladder & Other Cancers 0.317 0.296
HCC12 Breast, Prostate & Other Cancers/Tumors
0.154 0.198
HCC17 Diabetes w/Acute Complications 0.368 0.474
HCC18 Diabetes w/Chronic Complications 0.368 0.474
HCC19 Diabetes w/o Complications 0.118 0.182
HCC21 Protein-Calorie Malnutrition 0.713 0.399
HCC22 Morbid Obesity 0.365 0.579
Disease Coefficients Description Label Community Institutional
HCC23 Other Significant Endocrine & Metabolic Disorders
0.245 0.282
HCC27 End-Stage Liver Disease 0.923 1.083
HCC28 Cirrhosis of the Liver 0.399 0.351
HCC29 Chronic Hepatitis 0.251 0.351
HCC33 Intestinal Obstruction/Perforation 0.310 0.384
HCC34 Chronic Pancreatitis 0.286 0.095
HCC35 Inflammatory Bowel Syndrome 0.302 0.318
HCC39 Bone/Joint Muscle Infection/Necrosis 0.498 0.340
HCC40 Rheumatoid Arthritis & Inflammatory Connective Tissue Disorders
0.374 0.351
HCC46 Severe Hematological Disorders 1.136 0.794
HCC47 Disorders of Immunity 0.521 0.519
HCC48 Coagulation Defects & Other SpecifiedHematological Disorders
0.252 0.162
HCC54 Drug/Alcohol Psychosis 0.420 0.053
HCC55 Drug/Alcohol Dependence 0.420 0.053
Disease Coefficients Description Label Community Institutional
HCC57 Schizophrenia 0.490 0.311
HCC58 Major Depressive, Bipolar & Paranoid Disorders 0.330 0.311
HCC70 Quadriplegia 1.234 0.650
HCC71 Paraplegia 1.052 0.539
HCC72 Spinal Cord Disorders/Injuries 0.509 0.280
HCC73 Amyotrophic Lateral Sclerosis & Other Motor Neuron Diseases
0.958 0.367
HCC74 Cerebral Palsy 0.045 -
HCC75 Myathenia Gravis/Myoneural Disorders& Guillain-Barre Syndrome/Inflammatory & Toxic Neuropathy
0.408 0.300
HCC76 Muscular Dystrophy 0.565 0.215
HCC77 Multiple Sclerosis 0.556 -
HCC78 Parkinson’s & Huntington’s Disease 0.691 0.173
HCC79 Seizure Disorders & Convulsions 0.284 0.144
HCC80 Coma, Brain Compression/Anoxic Damage 0.570 0.104
HCC82 Respirator Dependence/Tracheostomy Status 1.520 1.769
Disease Coefficients Description Label Community Institutional
HCC83 Respiratory Arrest 0.802 1.169
HCC84 Cardio-Respiratory Failure & Shock 0.329 0.442
HCC85 Congestive Heart Failure 0.368 0.229
HCC86 Acute Myocardial Infarction 0.275 0.515
HCC87 Unstable Angina & Other Acute Ischemic Heart Disease
0.258 0.515
HCC88 Angina Pectoris 0.141 0.474
HCC96 Specified Heart Arrhythmias 0.295 0.262
HCC99 Cerebral Hemorrhage 0.339 0.216
HCC100 Ischemic or Unspecified Stroke 0.317 0.216
HCC103 Hemiplegia/Hemiparesis 0.581 0.061
HCC104 Monoplegia, Other Paralytic Syndromes 0.396 0.061
HCC106 Atherosclerosis of the Extremities with Ulceration or Gangrene
1.413 0.886
HCC107 Vascular Disease w/Complications 0.410 0.301
HCC108 Vascular Disease 0.299 0.107
Disease Coefficients Description Label Community Institutional
HCC110 Cystic Fibrosis 0.417 0.364
HCC111 COPD 0.346 0.364
HCC112 Fibrosis of the Lung & Other Chronic Lung Disorders
0.274 0.260
HCC114 Aspirations & Specified Bacterial Pneumonias 0.672 0.285
HCC115 Pneumococcal Pneumonia, Empyema, Lung Abscess
0.200 0.285
HCC122 Proliferative Diabetic Retinopathy & Vitreous Hemorrhage
0.203 0.433
HCC124 Exudative Macular Degeneration 0.335 0.166
HCC134 Dialysis Status 0.476 0.509
HCC135 Acute Renal Failure 0.476 0.509
HCC136 CKD Stage 5 0.224 0.509
HCC137 CKD, Severe Stage 4 0.224 0.294
HCC157 Pressure Ulcer of the Skin w/Necrosis through to Muscle/Tendon/Bone
2.488 1.050
HCC158 Pressure Ulcer of the Skin w/Full Thickness Skin Loss
1.338 0.435
Disease Coefficients Description Label Community Institutional
HCC161 Chronic Ulcer of Skin, Except Pressure 0.536 0.311
HCC162 Severe Skin Burn or Condition 0.411 0.327
HCC166 Severe Head Injury 0.570 0.104
HCC167 Major Head Injury 0.163 -
HCC169 Vertebral Fractures w/o Spinal Cord Injuries
0.497 0.228
HCC170 Hip Fracture/Dislocation 0.446 -
HCC173 Traumatic Amputations & Complications 0.265 0.122
HCC176 Complications of Specified Implanted Device/Graft
0.566 0.522
HCC186 Major Organ Transplant or Replacement Status
0.891 0.515
HCC188 Artificial Openings for Feeding or Elimination
0.651 0.594
HCC189 Amputation Status, Lower Limb/Amputation Complications
0.779 0.468
Variable Description Community Institutional
CANCER_IMMUNE Cancer*Immune Disorders 0.947 -
CHF_COPD CHF*COPD 0.259 0.221
CHF_RENAL CHF w/Renal Disease 0.317 -
COPD_CARD_RESP_FAIL COPD*Cardiorespiratory Failure 0.456 0.506
DIABETES_CHF Diabetes*CHF 0.182 0.189
SEPSIS_CARD_RESP_FAIL Sepsis*Cardiorespiratory Failure 0.456 0.506
ARTIF_OPENINGS_PRESSURE_ULCER
Artificial Openings for Feeding or Elimination*Pressure Ulcer
- 0.282
ASP_SPEC_BACT_PNEUM_PRES_ULCER
Aspiration & Specified Bacterial Pneumonias
- 0.495
COPD_ASP_SPEC_BACT_PNEUM COPD*Aspiration & Specified Bacterial Pneumonia
- 0.319
SCHIZOPHRENIA_CHF Schizophrenia*CHF - 0.212
SCHIZOPHRENIA_COPD Schizophrenia*COPD - 0.389
SCHIZOPHRENIA_SEIZURES Schizophrenia*Seizure Disorders & Convulsions
- 0.452
DISEASE INTERACTIONS
Variable Description Community Institutional
SEPSIS_ARTIF_OPENINGS Sepsis*Artificial Openings for Feeding or Elimination
- 0.553
SEPSIS_ASP_SPEC_BACT_PNEM Sepsis*Aspiration & Other Specified Bacterial Pneumonias
- 0.339
SEPSIS_PRESSURE_ULCER Sepsis*Pressure Ulcer - 0.522
DISEASE INTERACTIONS
YOUR TURN!!!
Creating your CDI Plan
Assess◦ Identify your most commonly used ICD10-CM codes, specifically those of chronic
conditions or injuries
◦ From those, identify any unspecified or “not otherwise specified” codes ◦ Example: J40 “Bronchitis, not specified as acute or chronic” (no HCC value) versus J41.0 “Simple chronic
bronchitis” (HCC 111)
◦ Identify patients who have had these codes submitted on their claims in the past 6 months and have a certified auditor/certified coder review the charts to perform a gap analysis of the documentation which may be preventing more specific coding.
◦ Review how providers are selecting the diagnosis codes that are being submitted (paper encounter form, EMR “favorites” list, etc.)
Implementation◦ Meet with the providers to discuss findings.
◦ Identify simple terms for providers to use in their documentation that can provide the necessary information to code to the highest specificity.
◦ Identify and explain gaps and/or deficiencies, as well as opportunities.
◦ Work with your IS/IT team to assist in creating more intentional templates in EMR. This is especially helpful for specialists, or for particular chronic conditions.
◦ Eliminate paper encounter forms if possible.
◦ Identify a Physician Champion if your practice is large enough, and enlist their help in educating the others. They can also offer great clinical feedback to the coders and/or auditors.
Creating your CDI Plan
Sustainability◦ Ongoing claims data analysis to monitor unspecified code usage
◦ Continued focused audits and feedback, especially to the providers most at risk
◦ Continued educational efforts using actual examples.
◦ Monitoring of claims not being paid upon initial submission and coming back with the request for “more information (CO-16), or “medical record requests” (M127)
◦ The use of technology wherever possible to allow your providers to concentrate on taking care of the patient instead of “being a coder”…
Creating your CDI Plan
Sample Progress Note
Patient: Female, age 74Chief Complaint: Follow up for multiple medical problems.HPI: DM2: Tries to watch her diet, average BS 110-180, compliant with Lantus 20 units QHSDiabetic Polyneuropathy: Burning in her feet improved on Neurontin x 3 mon use.PVD: Walks at mall daily, mid-calf pain after about 7 minutes, no history of injury, no CP, or SOB.Functioning colostomy secondary to UC. No change in output, no increased redness, followed by GI every six months S/P right great toe amputation. Denies any new foot or toe lesions.ROS: See HPICurrent medications, allergies and PMSH reviewed in HER today and no changes since last visit on April 14, 2015.Exam:BP 112/72 P76 WT 245 HT 5’3” BMI 41.5Older female NADHeart: Normal S1 S2 w/o murmurLungs: Easy respirations, CTAAbd: Soft, non-tender, colostomy intact, no ulcerations, amputation site well healed.Monofilament testing shows decreased sensation bilaterally.
Typical Assessment & Plan:1. Controlled DM Type II (EII.9) (E11.41)2. Peripheral Vascular Disease,
unspecified (I73.9)
Plan: Continue current diet and medication regime. Referral given for dilated retina exam. Referred for Diabetic Education. Fasting CMP & A1c prior to next appointment.
Demographic RAF:Female age 74 (0.348)
Diagnosis/es RAF: E11.9 DM II w/o complications
• HCC 19 (0.118) I73.9 PVD
• HCC 108 (0.299)
DX RAF: 0.417Demographic RAF: 0.348Total RAF: 0.765
Complete Assessment & Plan:1. Controlled DM II with neurologic manifestations (E11.41)2. Stable Peripheral Vascular Disease (I73.9)3. Long-term use of insulin (Z79.4)4. Artificial Opening Status-colostomy (Z93.3)5. S/P great toe amputation (Z89.411)6. Morbid Obesity (E66.01)
Plan: Continue current diet and medication regime. Referral given for dilated retina exam. Referred for Diabetic Education. Fasting CMP & A1c prior to next appointment
Demographic RAF:Female age 74 (0.348)
Diagnosis/es RAF: Morbid Obesity/BMI 41.5
• HCC 22 (0.365) E11.41 DM II w/neurologic complications
• HCC 18 (0.368) I73.99 PVD
• HCC 108 (0.299) Z93.3 S/P colostomy
• HCC 188 (0.651) Z89.411 right great toe amputation
• HCC 189 (0.779) DX RAF: 2.462Demographic RAF: 0.348
Total RAF: 2.810
Now your turn…
85 y.o. white female, symptoms of UTI.
HPI: Patient is tired, less energy and poor appetite and has had a heart attack (MI) 1 year ago. Patient has mild malnutrition, is frail and has lost 30 lbs. in the past 6 months. UA performed shows white cells, leukocyte esterase, and microalbuminuria. Serum albumin is 3.0 g/Dl. Serum creatinine is 1.4. Patient has been complaining of urinary discomfort, weakness, and has had dry and itchy skin for 6 months.
PMH: Stable DM, CKD exacerbated by DM, Left stable BKA, stable history of MI. GFR = 17 ml/min revealed CKD Stage IV.
Plan: Glucophage 500 mg. b.i.d. for DM, Cipro for UTI. Ensure supplement (drink) for malnutrition. RTC in 3 months. Referral to nephrologist for CKD IV.
The exercise is to review the note, and using the HCC table identify any conditions that could have an HCC category and value. Don’t forget to add the demographics as well.
Gender Age HCC Description Community Institutional RAF
Female 85 N/A Demographic Yes No 0.677
HCC18 DM w/renalmanifestations
0.368
HCC137 CKD Stage IV 0.224
HCC189 Right BKA 0.779
HCC 21 Mild protein malnutrition
0.713
Total: 2.761
Resourceshttps://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Risk-Adjustors.html
Questions? Comments?