™ obesity and malnutrition palliative care and dnr status uhc webinar series: mining the metrics...
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Obesity and MalnutritionPalliative Care and DNR Status
UHC Webinar Series:
Mining the Metrics of Risk Models
Presented by Suzanne Rogers, RHIA, CCS, CCDS
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May 30, 2012
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AgendaIntroduction to the UHC Webinar Series: “Mining the Metrics of Risk Models”
UHC Risk Adjustment: brief re-cap
Documenting & Coding Series Focus #1• Obesity, BMI• Malnutrition, BMI• End of Life
– Palliative care – Hospice– DNR
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UHC Mining the Metrics of Risk Models Webinar SeriesThe purpose of this series of webinars will be to highlight some of the diagnoses & procedures that impact the UHC risk adjustment models or have the potential to impact these models in the future
Goals & Objectives of the Series:• Quarterly webinars with documentation and coding educational focus that will:
− Demonstrate of how documentation and coding practice directly influences the administrative data used in benchmarking, performance improvement, and reimbursement
− Encourage accurate, compliant, and consistent documentation and coding practice throughout the UHC membership
− Explain the application of Official Coding Rules & Guidelines in a environment of federal regulations and audits
− Examine how current documentation and coding practice of the membership will impact future UHC risk adjustment models
− Measure improved consistency of coded and reported metrics Baseline data will be collected for each focus topic prior to the webinar and then monitored
going forward
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UHC Risk AdjustmentBrief Re-Cap
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UHC Clinical DatabaseUHC receives data from members throughout the year. Data is sent with a minimum of 45 day lag time to allow for the completion of coding and billing cycles
The data feed contains many data elements such as:
• ICD-9 diagnosis and procedures codes • Patient demographics such as age, race, sex • Admission source, admission status, and discharge disposition• Encounter physicians and their clinical specialty• Line item charge details • Primary and secondary payers
The MSDRG is not sent; UHC recalculates the MSDRG as well as a APR DRG for every inpatient encounter
UHC performs data quality checks, flags bad data which does not go to the data base, and applies the various risk adjustment models
The UHC clinical database risk adjusted data can be used for benchmarking and evaluating clinical care, patient outcomes and costs
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UHC Risk Adjustment: Brief Re-Cap
UHC recalibrates the CDB risk models annually
CDB discharges from major academic medical centers are used to build the models
A coefficient is assigned for each of the variables found to be statistically significant predictors of the outcome
Only conditions that are Present on Admissions (POA) are considered in the models
When using the database you can choose to report with the current (2011) or previous (2010) risk model
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Risk Model Information on Website
From UHC CDB/RM home page, select Documents & Presentations drop down list and choose Risk Methodology
The following screen should appear as a pop-up window
Choose the Risk Model Summary for 2011
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Many other resources that pertain to the risk models can also be found here such as:
• Diagnosis & ICD-9 codes that define the AHRQ Comorbidities
• ICD 9 diagnosis and procedures codes used in the risk models
• Variable definitions for MSDRG 2011 Models
• Definitions and tips on using the CDB
• Interactive Risk Model Calculator
Risk Model Information on Website Cont.
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You can use the Interactive Risk Model Calculator to calculate the risk adjustment for a particular encounter, to determine the impact of deleting or adding diagnoses or other data elements
Risk Model Information on Website Cont.
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Coding Accurately and Completely
A diagnosis may not be in current risk models but can only be tested for impact on clinical outcomes if it is coded• What is coded today can be important in developing FUTURE risk models
POA is an important aspect of developing and applying the risk models• Query if UNKNOWN• Blank POA = NO for risk adjustment
Demographic data elements are key components of the risk models• Patient age, admit source & admit status should be verified
Learn how to access, read, and apply the risk models• Match the model to the medical record. What got coded? What was missed?
What was the impact? Were the POA’s accurate?
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Obesity, Malnutrition and BMI
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Obesity, Malnutrition and BMI
Both obesity and malnutrition are factors in AHRQ risk adjustments for some Quality Indicators and Patient Safety Indicators
Both obesity and malnutrition are factors in UHC’s LOS, cost and mortality risk models
The ICD-9 diagnosis codes must have a POA of W, Y,1, or E to be considered in the risk adjustment process
The BMI V-Codes are EXEMPT from POA reporting and should appropriately be assigned ‘E’ or ‘1’ for POA exempt (do not leave blank)
POA indicators that are BLANK are translated to a N- Not Present on Admission for risk adjustment
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Obesity and Body Mass Index
Obesity currently a risk factor in 199 UHC risk models (57%)• Defined by codes:
– 278.00 Obesity unspecified– 278.01 Morbid obesity– 649.1X Obesity complicating pregnancy– 793.91 Image test inconclusive due to excess body fat– V85.30 Body Mass Index between 30-39, adult– V85.40 Body Mass Index between 40-49, adult– V85.54 Body Mass Index pediatric ≥ 95th percentile for age– Excludes MSDRG 640-641 Nutritional and Metabolic Disorders– Excludes MSDRG 619-621 Operating Room Procedures for Obesity
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Obesity Diagnosis UHC Model AHRQ
Co-MorbidityCMS – CC/MCC
278.00- Obesity NOS YES YES NO
278.01-Morbid obesity YES YES NO
278.02-Overweight NO NO NO
278.03-Obesity hypoventilation syndrome
NO NO CC
646.1X- Excessive weight gain in pregnancy
NO NO NO
649.1X- Obesity complicating pregnancy
YES YES NO
783.1- Abnormal weight gain NO NO NO
793.91-Image test inclusive; excessive body fat
YES YES NO
V85.30-V85.39- BMI between 30-39, adult
YES YES NO
V85.40-V85.45- BMI between 40-49, adult
YES YES CC
V85.54- BMI, pediatric >95th percentile for age
YES YES NO
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Obesity: Some Facts
A person is considered obese when his or her weight is 20% or more above normal weight
A person is considered obese if his or her BMI is over 30
"Morbid obesity" means that a person is either 50-100% over normal weight or has a BMI of 40 or higher
The CDC estimates that 30% of adults are obese and 17% of all direct medical costs in the US are related to obesity
Being overweight or obese severely interferes with health and normal function as well as increases risk of morbidity and mortality
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Reference: Adult Obesity Facts: Center for Disease Control and Prevention website
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Obesity Coding and CDI Opportunity
What to look for and query for definitive diagnosis• Body habitus and/or BMI is often documented by nursing as part of an
admission assessment (Joint Commission requires a nutritional assessment be done at admission)
• You may also find this in the H&P as part of the physical exam or review of systems
• Is the patient on a low fat diet or limited calories• Look for a dietary or nutrition consult or note• Are special measures being taken for imaging, transport or accommodations• Is there mention of poor imaging results due to body fat• Does OR report mention any difficulty or prolonged OR time due to the
patient’s size and/or amount of body fat?
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Obesity Coding Guidelines
A code for the BMI can be assigned from nursing/ dietician notes ONLY if the treating physician documents the associated clinical diagnosis of obesity, morbid obesity etc.
To be coded the diagnosis of obesity, it must be clinically significant to the patient’s current hospital stay (it almost always is, so look for any measures taken or conditions resulting from pts weight)• To be coded a secondary diagnosis must affect patient care in terms of
requiring:− Clinical evaluation− Therapeutic treatment− Diagnostic procedures− Extend LOS− Increased nursing care or monitoring
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Reference: AHA Coding Clinic
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Obesity Dx must be POA; logically it would have to be since the pt is not likely to become obese during the hospital stay, HOWEVER the physician must document it as such (Dx in the H&P, document the duration, longstanding, etc)
Educate physicians on the importance of documenting the condition of obesity/morbid obesity and the clinical significance this condition has on the patient’s care and disease process
Obesity Coding Guidelines Cont.
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Quarter 4, 2011: All Members
Diagnosis POA Cases 27800 - obesity nos
clinically undetermined, provider is unable to clinically determine whether condition was poa or not 3
no, not present at the time of inpatient admission 39
not reported to uhc 214
present at the time of inpatient admission 58,699
unknown, documentation is insufficient to determine if condition is poa 8
unreported/not used, exempt from poa reporting (1,e) 4
27801 - morbid obesity
clinically undetermined, provider is unable to clinically determine whether condition was poa or not 1
no, not present at the time of inpatient admission 13
not reported to uhc 100
present at the time of inpatient admission 34,967
unknown, documentation is insufficient to determine if condition is poa 3
unreported/not used, exempt from poa reporting (1,e) 2
6491X - obesity comp preg no, not present at the time of inpatient admission 8
not reported to uhc 12
present at the time of inpatient admission 7,223
79391 - imag inconc-excess fat no, not present at the time of inpatient admission 2
present at the time of inpatient admission 16
99% of Obesity Diagnosis are reported with a POA = Y
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Quarter 4, 2011: All Members
Diagnosis POA Cases
V8530-V8539-BMI 30-39 adult clinically undetermined, provider is unable to clinically determine whether condition was poa or not 1
no, not present at the time of inpatient admission 3 not reported to uhc 10,770 present at the time of inpatient admission 180
unknown, documentation is insufficient to determine if condition is poa 5 not used, exempt from poa reporting (1,e) 18,770
V8540-V8545 BMI 40 and over adult clinically undetermined, provider is unable to clinically determine whether condition was poa or not 1
no, not present at the time of inpatient admission 9 not reported to uhc 10,062 present at the time of inpatient admission 284
unknown, documentation is insufficient to determine if condition is poa 1 not used, exempt from poa reporting (1,e) 19,796 V8554 -BMI >=95% for age pedi not reported to uhc 185 present at the time of inpatient admission 6
not used, exempt from poa reporting (1,e) 210
33-36% of adult BMI in obese pts are reported to UHC without a POA indicator 46% of pedi BMI in obese pts are reported to UHC without a POA indicator
Assign POA indicator “1 or E” for Exempt so that the BMI codes can be used to calculate risk adjustment
(POA’s that are BLANK = “NO” in risk models)
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How to Report on Your Obesity Dx POA Assignment
Exclude MSDRG’s
619-621 & 640-641(per AHRQ definition)
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Click on underlined numbers to drill down to case profile
Create an Advanced Restriction:
AHRQ CC obesity codes and
POA Flag- include all
Save your advanced restriction as a custom list
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Save your report by using the Save icon
In Save Report: popup window give your report a name and file it under a existing or new group and click save
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Case #1 DRG 439 Disorder of Pancreas w/ CC
1. BMI present on admission indicator left blank & No Dx of morbid obesity coded. If added would increase Exp Mort to 0.53705 and Exp LOS to 3.53
2. Combo of morbid obesity, OSA & hypoxemia consider QUERY for pickwickian syndrome for second CC
58 yr Black Male Obsv LOS 12 days / Expected LOS 3.42Expected Mortality 0.00205
Diagnosis ICD-9 POA Mort Variable LOS Variable
Acute pancreatitis
577.0 Yes- PDX NA NA
BMI 50-59.9 V85.43 BLANK (exempt) 0.535 0.1107
Hypoxemia 799.02 YES NA NA
OSA 327.23 YES NA NA
HTN 401.9 YES NA NA
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Malnutrition and BMI
Malnutrition currently a risk factor in 224 UHC risk models (64%)• Defined by Codes:
– 260 Kwashiorkor– 261 Nutritional marasmus– 262 Other severe protein-calorie malnutrition– 263.0 Malnutrition of moderate degree– 263.1 Malnutrition of mild degree– 263.2 Arrested development following protein-calorie malnutrition (nutritional dwarfism)
– 263.8 Other protein-calorie malnutrition– 263.9 Unspecified malnutrition– 783.21 Loss of weight– 783.22 Underweight– Excludes MSDRG 640-641 Nutritional and Metabolic Disorders
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Malnutrition
Diagnosis UHC Model AHRQ Co-morbidity CMS CC/MCC
260- Kwashiokor YES YES MCC
261- Nutritional marasmus YES YES MCC
262-Other severe protein- calorie malnutrition YES YES MCC
263.0- Moderate malnutrition YES YES NO
263.1- Mild malnutrition YES YES NO
263.2-Arrested development following protein- calorie malnutrition
YES YES CC
263.8- Other protein-calorie malnutrition YES YES CC
263.9- Unspecified protein-calorie malnutrition YES YES CC
783.21- Loss of weight YES YES NO
783.22- Underweight YES YES NO
783.41- Failure to thrive, child NO NO NO
783.7- Adult failure to thrive NO NO NO
779.34- Failure to thrive, newborn NO NO YES
V85.0- BMI <19, adult NO NO CC
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Malnutrition: Some Facts
Currently there is no authoritative definition for the diagnosis or severity of malnutrition …..May 2012 Academy of Nutrition and Dietetics issued a consensus statement Identification & Documentation of Adult Malnutrition (Undernutrition)• Continuum of characteristics or variables, no one marker for malnutrition• Inadequate intake, increased requirements, impaired absorption, altered
transport, altered nutrient utilization can cascade into malnutrition• Inflammation is identified as an important underlying factor
– Albumin /pre-albumin are indicators of the inflammatory response and not malnutrition
• Two or more of the six characteristics recommended for diagnosis– Insufficient energy intake– Weight loss– Loss of muscle mass– Loss of subcutaneous fat– Localized or generalized fluid accumulation– Diminished functional status (hand grip)
Reference: Journal of the Academy of Nutrition and Dietetics May 2012 Vol.112 number 5
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Figure. Etiology-Based Malnutrition Definitions. Adapted with permission from reference (8): Jensen GL, Bistrian B, Roubenoff R,Heimburger DC. Malnutrition syndromes: A conundrum vs. continuum. JPEN J Parenter Enteral Nutr. 2009;33(6):710-716.
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Diagnosis is usually based on several factors including some or all of the following:• Physical appearance:
– Cachexia, atrophy, emaciation, unintended or unexpected weight loss
• Risk factors: – Cancer, chemotherapy, ETOH, GI or pancreatic disorder, trauma, inflammatory
responses, recent GI surgery
• Test results: – Albumin as marker of inflammation, BUN, CBC, protein stores
• None of these tests are markers for diagnosis rather they indicate underlying etiology for susceptibility
• History: – Recent or rapid weight loss, decreased functionality, recent trauma or other stress on patient physiology
Malnutrition: Some Facts Cont.
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Malnutrition: Coding and CDI Warning
The terms “severe malnutrition”, “severe calorie deficiency”, “protein malnutrition”, “emaciation”, “protein deficiency”, “nutritional atrophy”
Code to either:• Kwashiorkor (260)• Nutritional marasmus (261)
Both these conditions are highly unlikely to occur in the general population and are usually associated with children in third world countries
Both these codes are current targets for review and denial by the OIG & RAC’s
Assign codes from category 263- Other and unspecified protein-calorie malnutrition
Educate the physicians on the terminology and code assignment
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Malnutrition: Coding and CDI Opportunity
Look for CLUES and query for clinical significance and/or definitive diagnosis (must meet the criteria for a reportable secondary diagnosis)
• BMI <19 in nursing, dietary notes• Patient reported “loss of weight” (783.21) in H&P• Physical exam noted: underweight, cachexic, very thin or frail, failure to thrive• Conditions associated w/malnutrition such as, cancer and cancer treatment,
HIV, s/p GI surgery, depression, prolonged illness and/or hospitalization, elderly, pancreatic disease, ETOH or drug abuse, swallowing difficulties
Educate the physicians on the coding rules and code assignment
Malnutrition can be coded even if it is the result of or an expected manifestation of the underlying disease such as cancer or pancreatic disorders
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Look for CLUES in treatments and orders and query for definitive diagnosis
• TPN or other enteral feeding• Ensure, Boost, Carnation Instant Breakfast and other high protein/ high calorie
supplements• Swallowing studies, GI consult, nutrition consult, OT/PT – ADLs
Look for clinical evidence of malnutrition and/or treatment at admission A patient rarely becomes malnourished during a routine hospital stay
Educate and query for malnutrition documentation in the H&P, admit note or designated as being present on admission
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Malnutrition: Coding and CDI Opportunity Cont.
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Quarter 4, 2011 All MembersDiagnosis POA Cases
260 - kwashiorkor no, not present at the time of inpatient admission 16 present at the time of inpatient admission 95 261 - nutritional marasmus clinically undetermined, provider is unable to clinically determine whether condition was poa or not 3 no, not present at the time of inpatient admission 529 not reported to uhc 5 present at the time of inpatient admission 3,130 unknown, documentation is insufficient to determine if condition is poa 2 262 - oth severe malnutrition clinically undetermined, provider is unable to clinically determine whether condition was poa or not 3 no, not present at the time of inpatient admission 754 not reported to uhc 2 present at the time of inpatient admission 4,169 unknown, documentation is insufficient to determine if condition is poa 3 2630 - malnutrition mod degree clinically undetermined, provider is unable to clinically determine whether condition was poa or not 2 no, not present at the time of inpatient admission 641 not reported to uhc 1 present at the time of inpatient admission 3,318 unknown, documentation is insufficient to determine if condition is poa 5 2631 - malnutrition mild degree no, not present at the time of inpatient admission 321 present at the time of inpatient admission 1,745 unknown, documentation is insufficient to determine if condition is poa 3 2632 - arrest devel d/t malnut present at the time of inpatient admission 9
2638 - protein-cal malnut nec no, not present at the time of inpatient admission 119 present at the time of inpatient admission 737 2639 - protein-cal malnut nos clinically undetermined, provider is unable to clinically determine whether condition was poa or not 13 no, not present at the time of inpatient admission 5,221 not reported to uhc 21 present at the time of inpatient admission 16,434 unknown, documentation is insufficient to determine if condition is poa 36 78321 - loss of weight no, not present at the time of inpatient admission 717 not reported to uhc 28 present at the time of inpatient admission 9,109 unknown, documentation is insufficient to determine if condition is poa 1 78322 - underweight not reported to uhc 4 present at the time of inpatient admission 1,135
In 17% of the cases the POA indicator did not allow the DX to be considered for risk adjustment:
POA= No, Blank, Unknown
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Report on Your Malnutrition Coding Performance
Create an Advanced Restriction: Exclude MSDRG 640
Create an Advanced Restriction: AHRQ CC malnutrition codes & POA flag- include all(be sure to save your Advanced Restriction as a custom list for future reporting)
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In this example 21% of malnutrition codes are indentified as:
POA =No, Not Present on Admission
Click on underlined case numbers to drill down to case profiles
Report on Your Malnutrition Coding Performance Cont.
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Look for clues of present on admission Pt started on enteral nutrition on admission
LOS is only 4 daysPt has oral cancerPt has a trach and gastrostomy
Query for diagnosis based on treatment and pts comorbidties
Clarify this diagnosis is 262 Other severe protein-calorie malnutrition more appropriate
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Change “sort by” to Discharge Phys Specialty
Change Advanced Restriction to POA =N
Focus on General Medicine:
Perform some chart reviews to substantiate
Provide education for CDI, coders and Gen Med physicians based on finding and examples
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Palliative Care and DNR
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Palliative Care and DNR (Do Not Resuscitate)
Palliative care (V66.7) is in 27 UHC risk models• Exempt from POA reporting• Always coded as a secondary diagnosis
New code for Do Not Resuscitate (V49.86)• POA required• Not in risk models yet, but data is being collected for future consideration
As of July 2012, palliative care will no longer exclude a case from Core Measures• Comfort care or DNR must be documented for exclusion
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Palliative Care (V66.7): Some Facts
The National Institutes of Health defines palliative care as relief of symptoms without curing disease. Hospice care, care at the end of life, always includes palliative care. But you may receive palliative care at any stage of a disease. The goal is to make you comfortable and improve your quality of life.
CMS does not consider palliative care, hospice care, or comfort care synonymous even though the code assigned for all will be V66.7
The level and type of care being given must be clearly documented in the record for Core Measures reporting and hospice reimbursement
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Some indications of palliative care could be:
• Withdrawal of any treatment or therapy (e.g. extubation, d/c-ing antibiotics, vasopressors, other therapeutic drugs
• Addition or increase of opiates and other pain relief treatments • Treating symptoms, but not the cause/disease (e.g. drainage, relief of
pressure, enteral feeding, oxygen by nasal cannula etc)• Transfer out of critical care setting, possibly to specialized palliative care
unit/bed or even hospice
Remember palliative care can be given in non-terminal cases, it is not always end of life
Palliative Care (V66.7): Some Facts Cont.
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DNR (V46.89): Some Facts
DNR (do not resuscitate) is a physician order not to perform CPR or ACLS• Can also be called a “no –code” or DNR/DNI
Palliative care and DNR/DNI are not the same
Patient can be a DNR and NOT be on palliative care & vice versa • You can not assume one because the other is documented
Patient can be DNR on admission or can request DNR status anytime during an admission. • Living will, advanced directives
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Palliative Care & DNR- Coding & CDI Opportunities
If a patient is on palliative care look for evidence of a DNR, and query for physician documentation so both can be coded
• DNR/DNI may be documented in nursing notes, social worker or other care provider note
• For DNR to be coded it must be documented by a treating physician
If a patient/family decide on withdrawing treatment and/or transfer to hospice, be sure to have that documented and code the V66.7 if comfort measures are started prior to transfer
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Palliative Care & DNR- Coding & CDI Opportunities Cont.
Provide general education to physicians on how to document palliative care, comfort care and DNR as well as the dying process as appropriate• Remember the patient does not need to be terminal to be receiving palliative care or
have a DNR order
When a patient is DNR or on palliative care and they die; look for the associated conditions of the dying process and query physician to document
Do not miss out on documentation and coding of CC’s, MCC’s diagnoses of the dying process
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The Dying Process: What Might not be Documented/Coded
Diagnosis Codes CC MCC
Metabolic disorders 276.0-276.4 X
Encephalopathies 348.30-348.39, 349.82 X
Brain death 348.82 X
Cerebral anoxia/hypoxia 348.1 X
Cardiac arrest (if d/c to hospice) 427.5 X
Respiratory failure & insufficiency 518.51-518.53, 518.81-518.84
X X
Acute renal failure 584.5-584.9 X X
Coma/comatose 780.01 X
Persistent vegetative state 780.03 X
Cheyne-stokes respirations 786.04 X
Asphyxia/hypoxia 799.01 X
Respiratory arrest 799.1 X
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Resource
Addendum: Table of risk models with obesity, malnutrition and palliative care is included as a hand out for use in identifying impact of these codes on the various risk models
Risk Model
OBESITY MALNUTRTION PALLIATIVE
LOS Cost Mortality LOS Cost Mortality Mortality1 0.203423077 4 0.548716643 5 6 7 0.129202691 1.015232299 8 3.3872056359 0.076908462
10 2.57120527411 0.122894774 0.149794168 0.10108957 12 0.03836161 0.1342281 0.057100581 13 0.056922592 14 -0.100704352 0.194663018 15 0.471439915 16 0.260835903 0.18100325 17 0.062597034 0.310414249 0.178277158 18 0.390426606 0.42365652 19 0.136392405 0.223980777 0.151933555 3.39650273820 0.187640685 -0.080007655 21 0.15128321 22 23 0.057776625 0.077372606 24 25 0.057141883 0.05336678 0.195627179 26 0.190263684 27 0.086787678 0.076376272 0.339436109 0.271172886 1.468691594
