Alabama HIMA: Clinical Documentation Transformation

April 14, 2016

Disclaimer

• This material is designed and provided to communicate information about inpatient coding, clinical documentation, and/or compliance in an educational format and manner

• The author is not providing or offering legal advice but, rather, practical and useful information and tools to achieve compliant results in the area of clinical documentation, data quality, and coding

• Every reasonable effort has been taken to ensure the educational information provided is useful and accurate

• Applying best practice solutions and achieving results will vary in each hospital/facility and clinical situation

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Discussion Topics

• Evolution and Differences of DRG systems and the impact on clinical data

• Overview of APR DRG Methodology

• Public Reporting and Why it Matters

• Collaborate and Build a Team

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Discussion Topics • Evolution and Differences of DRG systems and the impact on clinical data

– History of DRGs – MS DRGs – APR DRGs

• Medical Record is the core / foundation for clinical data management – RAC Audits – Compliance – Severity of Illness (SOI) and Risk of Mortality (ROM) – Profiling Hospitals and Physicians – Hospital Acquired Conditions

• Public Reporting and Why it Matters – Healthgrades.com – Hospitalcompare.gov – Qualitycheck.org – Data.gov

• Collaborate with Leadership to gain support for the CDI Program – Establish a Steering Committee – Establish an Operational Committee – Select a Physician Champion

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Brief History of DRGs

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American Health Information Management Association. “Evolution of DRGs (updated).”

Journal of AHIMA (Updated April 2010) Copyright ©2016 by the American Health

Information Management Association. All rights reserved.

Medicare Severity (MS) DRGs

• MS DRGs were implemented October 1, 2007 to better recognize severity of illness

– The MS DRGs were a significant improvement but it does not account the actual complexity of the Medicare population

• Does not capture multiple additional comorbidities or complications

– MS DRGs have a three-tiered structure

• MCC

• CC

• Without MCC/CC

– In the public domain

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3M™ APR DRGs: Beyond Resource Use

Development of a new method and refinement to evaluate hospitals

• Evaluate hospitals across an extensive range of outcome and resource measures

• Evaluate variances in inpatient mortality rates

• Implement and support of critical pathways

• Identification of continuous quality improvement projects

• The need for a system to accurately capture “Case Mix Complexity”

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3M™ APR DRGs

• Overview: – All Patient Refined Diagnostic Related Group

– Developed by 3M • AP DRGs used initially as the base

• Yale’s R DRGs incorporated

• PM DRGs (pediatric modification) National Association of Children’s Hospitals and Related Institution were integrated

– Much more clinically uniform and similar

– Calculates a severity of illness (SOI)

– Calculates a mortality risk (ROM)

– Takes resource intensity into consideration • Captures differences in the patient’s complexity of illness

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3M™ APR DRGs

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http://solutions.3m.com/wps/portal/3M/en_US/Health-Information-Systems/HIS/Products-

and-Services/Products-List-A-Z/APR-DRG-Software/

Factors Used to Calculate 3M™ APR DRGs – Case Mix Complexity

Factors used to

Calculate APR DRGs

Severity of illness

Risk of mortality

Prognosis

Treatment difficulty

Need for intervention

Resource intensity

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National Depth of Coding Trends

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Definition of Severity

• Severity of illness (SOI) is defined as the degree of physiological decomposition of body systems – What does this mean?

• Severity describes how ill a patient is and what resources are required to treat a patient

• Risk of mortality (ROM) is the likelihood of dying

• Resource Intensity is the relative volume and types of diagnostic, therapeutic and bed services used in the management of a particular disease

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APR DRG Levels –

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Benefits

Adjust for SOI

Reimburse appropriately

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MDCs

2 Subclasses

Severity of Illness [SOI]

Risk of Mortality

[ROM]

1 Minor

2 Moderate

3 Major

4 Extreme

311 APR DRGs

+

3 Unrelated APR DRGs

2 Invalid APR DRGs

• Each SDx* → SOI and ROM value

• Each DRG → SOI and ROM value

* Some exclusions apply

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Severity DRG Decision Flow

MDC

Assignment

PDx Selection

Valid Procedure?

Medical Severity DRG

Surgical Severity DRG

SDx Selection

Interaction between PDx, each SDx SOIs and Procedures

Severity DRG

DRG SOI

DRG ROM

1 Minor

2 Moderate

3 Major

4 Extreme

SDx SOI

SDx ROM

1 Minor

2 Moderate

3 Major

4 Extreme

Key Concepts: Overall SOI Assignment Overall SOI assignment

• All ICD-10-CM diagnosis codes have a default severity of illness (SOI) level

– Minor (1)

– Moderate (2)

– Major (3)

– Severe (4)

• Secondary diagnosis (SDx) SOI levels do not “count” when the diagnosis is used as the principal diagnosis (PDx)

– UTI as SDx = SOI 2

– UTI as PDx = APR DRG 463: Urinary Tract Infection - SOI of 1

• The default SOI maybe excluded, promoted, or demoted based on its relationship with the principal diagnosis (PDx)

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Approach to 3M™ APR DRGs – Rerouting Logic

• Rerouting Logic – Unique to APR DRGs

– Overly broad principal diagnosis

– Sequencing of principal and secondary diagnosis is blurred or indistinct

• Re-routing logic reassigns the patient to a new APR DRG or SOI

– Within the same MDC (Within MDC Rerouting)

– Across MDCs (Across MDC Rerouting)

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Patient 1

Code Description SOI

PDX I63.9 Cerebral Infarct

SDx A41.9 Sepsis, NOS 3

SDx J69.0 Aspiration PNA 4

SDx N39.0 UTI 2

SDx A49.8 E. Coli 1

APR DRG 045: CVA w/ Infarct

Severity Level: 3 (Major)

MDC 001: Nervous System

Patient 1

Code Description SOI

PDX I63.9 Cerebral Infarct

SDx A41.51

Sepsis due to E. Coli

4

SDx J69.0 Aspiration PNA 4

SDx N39.0 UTI 2

SDx A49.8 E. Coli 1

APR DRG 045: CVA w/ Infarct

Severity Level: 4 (Extreme)

MDC 001: Nervous System

Secondary Diagnosis SOI Adjustment: Promotion

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Additional specificity of sepsis will “promote” or increase the SOI level

Secondary Diagnosis SOI Adjustment: Demotion

The SOI is demoted or decreased in this example because pleural effusion is typically seen in CHF patients; however, in this example, the patient had a thoracentesis so we can report the pleural effusion. (AHA Coding Clinic 3rd Quarter 1991 pg. 19 – 20)

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Patient 1

Code Description SOI

PDx I48.91 A-Fib

SDx J90 pleural effusion 3

SDx J18.9 PNA 3

APR DRG 201: Cardiac Arrhythmia & Conduction Disorders

MDC 5: Diseases & Disorders of the Circulatory System

Patient 1

Code Description SOI

PDx I50.9 CHF

SDx J90 pleural effusion

2

SDX J18.9 PNA 3

PPx 0W9B3ZZ Thoracentesis

APR DRG 194: CHF

MDC 5: Diseases & Disorders of the Circulatory System

Age Modification: Secondary Diagnosis SOI Impact

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Diagnosis Default SOI Criteria Age SOI Impact

Dehydration 1 ≥ 70 y/o 2

ESRD 2 < 18 y/o 3

Hematuria 1 < 1 y/o or ≥ 80 y/o 2

Cellulitis Upper Limb

1 ≥ 65 y/o

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Age Modification

Comparison of MS DRG to APR DRG

DIAGNOSIS ICD-10 Code

MS DRG APR DRG

Hyponatremia E87.1 CC SOI 2

Hypernatremia E87.0 CC SOI 3

History of pancreas transplant

Z94.83 CC SOI 3

Combined systolic and diastolic heart failure, acute on chronic

I50.43 MCC SOI 3

Acute renal failure N179 CC SOI 3

Pneumonia NOS J189 MCC SOI 3

UTI N390 CC SOI 2

CHF NOS I50.9 Not a CC/MCC SOI 2

Thrombocytopenia D69.6 Not a CC/MCC SOI 2

Diagnoses Potentially Missed • Homelessness Z59.0 (1)

• Kidney transplant status Z94.0 (2)

• Dependence on supplemental oxygen Z99.81 (2)

• Liver transplant status Z94.4 (3)

• Dependence on respirator (ventilator) status Z99.11 (4)

• Colostomy status Z93.3 (1)

• Attention to colostomy Z43.2 (2)

• Nephrostomy status Z93.6 (2)

• Attention to nephrostomy Z43.6 (1)

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Diagnoses Potentially Missed

• Morbid obesity due to excess calories E66.01 (2)

• Noncompliance with medications in psych patients (e.g. schizophrenia, unspecified Z91.14) (SOI 2 only in PSY PDx)

• Suicidal/Homicidal Ideation R45.851 (2)

• Awaiting organ transplant Z76.82 (3)

• Vitamin Deficiency E56.9 (2)

• Failure to Thrive (adult) R62.7 (2)

• Hypothermia, initial episode T68XXXA (2)

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Impact of Documentation

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Documentation

Severity of Illness and

Risk of Mortality

Reimbursement

Medical Necessity and

Length of Stay

Profiling Hospital and Physicians

Present on Admission and HACs

RAC Audits and

Compliance

Clear, complete, timely and accurate documentation has a significant impact on many facets of fiscal and operational data that will continue to increase with

healthcare reform

Hospital Data in the Public Domain

• healthgrades®

• Hospital Compare (CMS.gov)

• American Hospital Directory®

• The Joint Commission, Quality Check®

• The Leapfrog Group

• Truven Health Analytics™

• US News & World Report – Best Hospitals

• Consumer Reports

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PEPPER Resources • PEPPER – Program for Evaluating Payment Patterns Electronic

Report – PEPPER is an electronic data report that contains statistical

claims data for MS DRGS at risk for improper payment due to billing, coding, and/or medical necessity

– The findings from PEPPER can be used to develop auditing and monitoring action plans

• PEPPER distributed quarterly for Short-term Acute Care Hospital through the Secure PEPPER portal or through QualityNet

• Compare Targets Report – Compares the hospital’s target discharges at the national

and state level – Identifies the hospital’s outlier status as high, low, or into

the expected range

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Using PEPPER Example of

Target Areas Suggested Interventions for High

Outliers (if at or above 80th percentile)

Suggested Interventions for Low Outliers (if at or below 20th percentile)

Simple Pneumonia

Could indicate coding or billing errors related to DRGs 193 or 194; ensure documentation supports the principal diagnosis

Could indicate that there are coding or billing errors related to under-coding DRGs 193 or 194; consider a sample review of DRGs 177, 178, and 189

Septicemia Could indicate coding or billing errors related to over-coding DRGs 870, 871, or 872; consider a sample review of cases with a principal diagnosis of 038.9 (unspecified septicemia to ensure the documentation supports the principal diagnosis

Could indicate there are coding or billing errors related to under-coding 870, 871, or 872; consider a sample review from other DRGs, such as DRGs 689 and 690

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Using PEPPER Example of

Target Areas Suggested Interventions for High

Outliers (if at or above 80th percentile)

Suggested Interventions for Low Outliers (if at or below

20th percentile)

Medical DRGs with CC or MCC

Could indicate that there are coding errors or billing errors related to over-coding

Could indicate that there are coding or billing errors related to under-coding

Stroke intracranial hemorrhage

Could indicate potential over-coding. A sample of medical records for DRGs 061, 062, 063, 064, 065, 066 should be reviewed to determine if coding errors exist

Could indicate that there are coding or billing errors related to under-coding of DRGs 061, 062, 063, 064, 065, and 066. A sample of medical records for other DRGs, such as DRGs 067, 068, and 069 should be considered to determine if coding errors exist.

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Office of Inspector General (OIG) FY 2016 Work Plan • The responsibility of the OIG

– Protect the integrity of Health and Human Service (HHS) programs and the well-being of beneficiaries by detecting and preventing fraud, waste, and abuse

• Outcomes FY 2015 – 4,112 individuals and entities excluded from participation in

Federal health care programs – 925 criminal actions against individuals or entities that engaged

in crimes against HHS programs – 682 civil actions which include false claims and unjust-

enrichment lawsuits filed in Federal district court

• Expected recovery for FY 2015 greater that $3 billion • Estimated savings for FY 2015 approximately $20.6 billion

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Office of Inspector General

• FY 2016, Examples of OIG Focus – Inpatient claims for mechanical ventilation (still active)

• Review of claims with mechanical ventilation of greater than 96 hours; inappropriate billing identified for patients for patients who received less than 96 hours of mechanical ventilation

– Payments for patients diagnosed with kwashiorkor (still active) • Claims that include the diagnosis of kwashiorkor will be

reviewed to determine if the documentation supports the diagnosis; OIG previously identified inappropriate payment for claims with kwashiorkor

– Medicare payments during MS-DRG payment window (new) • Review of Medicare payments to acute care hospitals to

determine if certain outpatient claims billed to Medicare Part B for services provided during inpatient stays were allowable and in accordance with the IPPS

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Office of Inspector General

• The Office of Inspector General encourages hospitals to develop and implement compliance programs to protect the organization from fraud and abuse

– Hospitals should conduct regular audits to ensure services are appropriately documented and billed

• Implement an internal data mining process to identify areas of vulnerability

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POA Indicators • Indicators

Y – Condition was present on admission

N – Condition was NOT present on admission

W – Provider is unable to clinically determine whether condition was present on admission or not

U – Documentation is insufficient to determine if condition is present on admission

E – Diagnosis is exempt from POA reporting

• “W” will be treated the same as “Y” by CMS

• “U” will be treated the same as “N” by CMS

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Present on Admission Definitions

• Federally defined as present at the time the order for inpatient admission occurs

– Conditions that develop during an outpatient encounter,

including

• Emergency department

• Observation

• Outpatient surgery

– Are considered to be present on admission

• Timing of documentation DOES NOT MATTER

– Physician may document that a diagnosis was present on admission at any time, including discharge summary or post-discharge query

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Present on Admission Definitions

• A diagnosis is considered to be ‘present on admission’ if

– The condition was diagnosed during the admission, but was clearly present on admission

• Chronic conditions

• Cancer

– The diagnosis was possible, probable, rule out, suspected, differential on admission, and was confirmed at discharge

– The condition developed during an outpatient encounter, such as emergency room, physician office, outpatient surgery or observation

– The signs and symptoms of the condition were clearly present on admission and listed later in the record as a diagnosis

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Quality Initiatives

• CMS Hospital Quality Programs

– Inpatient Quality Reporting (IQR) • Chart abstracted measures

• Claims based measures

• Patient reported measures

• Facility reported measures

• Soon to include electronic clinical quality measures

– Value Based Purchasing (VBP) • Chart abstracted measures

• Claims based measures

• Patient reported measures

• Facility reported measures

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Quality Initiatives • CMS Hospital Quality Programs

– Hospital Readmission Reduction Program (HRRP)

• Claims based measures

– Hospital Acquired Conditions (HAC)

• Claims based measures

• Facility reported measures

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Hospital Acquired Conditions (HACs)

• The Deficit Reduction Act of 2005 required the identification of conditions that are

– High cost , high volume, or both

– Result in the assignment of a case to a DRG that has a higher payment when present as a secondary diagnosis

– Could reasonably have been prevented through the application of evidence-based guidelines.

• In FY 2015 the Affordable Care Act required the implementation of imposed financial penalties for hospitals performing poorly regarding HACs

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Hospital Acquired Conditions (HACs) Domain 1 (15%) • Accidental puncture or laceration • Perioperative pulmonary embolism or DVT • Post-op sepsis • Iatrogenic pneumothorax • Central venous catheter-related blood stream infection • Pressure ulcer – Stage 3 and 4 (or unstageable) • Post-op wound dehiscence • Post-op hip fracture Domain 2 (85%) • CLABSI (central line associated blood stream infection) • CAUTI (catheter associated UTI) • Surgical site infections (SSI) for total hysterectomy and colon surgery • MRSA infection • Clostridium difficile infection

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Hospital Acquired Conditions (HACs) • The responsibility of the CDS

– Thoroughly review the record to determine if the condition is present on admission

– Thoroughly review the record to determine if the condition is clinically valid

• If clarification is needed, query the physician

– If after review the condition is determined to be hospital acquired, refer the case to the Quality

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Develop Team Approach • Build alliances and work as a team to achieve successful

outcomes

– Patient Access

– Case Management

– Revenue Cycle

– Denials Management

– Quality Department

COMMUNICATE…COMMUNICATE…COMMUNICATE

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CDSs and Coders – Partner in Success • Partner with the HIM Coders to achieve successful outcomes

• Participate in HIM quarterly meetings to review Coding Clinics and annual coding updates

• Understand what queries are generated retrospectively and generate the queries concurrently when possible

• Reconcile concurrent worksheets with the final coding

– This should be approached as a learning opportunity

• Develop joint education for CDSs and coders

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Comprehensive and Holistic Approach for Record Reviews

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Clinical

Indicators

↓

Diagnosis

Diagnosis

↓

Clinical

Indicators

Present on Admission

(POA)

NO MORE NO LESS

Establish a CDI Steering Committee

• Support from the Leadership Team is essential to the initial and continued success of the CDI Program

• If the program is new or in the process of being “reinvigorated” or if the program is established without a CDI Steering Committee, institute and memorialize specific responsibilities for the CDI Steering Committee

• For new programs, the CDI Steering Committee typically meets every other week and once a month after implementation for the first year and then quarterly

• Once CDI is operationalized within the organization, this committee may stop meeting: – If the CDI Program falters, this committee should be reconvened

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CDI Steering Committee Members

• Include key leaders from executive management

– CEO – CFO – CMO/VPMA – CIO – Providers (e.g., Hospitalists, Community Providers, Surgeons) – Compliance Officer – CDI Internal Executive Leader – CDI Director/CDI Program Manager – CDI Provider Educators – HIM Director – Coding Manager – Quality Director

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CDI Steering Committee Responsibilities

• Responsibilities (primary) include

– Obtain and maintain medical staff support – Create a chain of command to manage uncooperative or

recalcitrant providers (e.g. Escalation Policy) – Support the CDI Program financially (especially when new or in

the process of reinvigoration) – Determine key metrics for review at the strategic level

• Review rate, query rate, response rate, impact (SOI/ROM and Case Mix Index)

– Provide feedback to the CDI Operational Committee and Providers • Ensure there is a strategic communication process in place to share

metrics and recognize future challenges

– Guide corrective action when necessary

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Establish a CDI Operational Committee

• This committee is responsible for the day-to-day operations,

management and support for the CDI program • Meets weekly (if new or in the process of reinvigoration) and

then monthly or quarterly • Committee members may include

– CDI Internal Executive Leader – CDI Director/CDI Program Manager (if different from above) – CDI Provider Educator – Compliance Officer – Directors of HIM, Quality and Case Management – Clinical Documentation Specialist(s) – Coding Supervisor or Coding professionals (dependent on size) – Data Analyst

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CDI Operational Committee Responsibilities

• Responsibilities (primary) include

– Hire and train staff – Oversee provider and ancillary clinical staff training – Implement and manage day-to-day activities (querying,

record review, one-on-one provider training) – Review program data for tracking and trending – Supervise the design of auditing clinical documentation

functions – Supervise the design of follow-up provider training – Disseminate key metrics to the CDI Steering Committee

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Physician Champion – Key to CDI

• A Physician Champion/Liaison is paramount to the success of a CDI program

• The Physician Champion should be well known and highly respected by the medical staff

• Other attributes of an “ideal” Physician Champion include – Practice experience in the community – Generalist FP/IM – Utilization background/experience – Past Chief of Medical Staff or Medical Service – History of good documentation practices – Proactive for hospital policy implementation – Non confrontational

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Physician Champion

• Responsibilities include

– Liaise with CDI staff

– Interacts with the medical staff

– Attends “Kick off” and implementation meeting for CDI (if new or reinvigoration)

– Attends Medical Executive Committee meetings

– Attends meetings of the Committee

– Helps review and/or writes information letters to staff

– Discusses any problem that arises with the documentation process with regard to physician acceptance

– Advocates for the providers’ continued high-quality documentation

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TEAR DOWN THE SILOS AND

WORK AS A TEAM

THANK YOU...QUESTIONS?

• Joni Dion, RHIA, CDIP, CCDS, CPC, CRC – AHIMA Approved ICD-10-CM/PCS Trainer – jdion@thinkbrg.com – (614) 256-2341

• Bonnie Peters, CCDS, CDIP, CCS-P, CPC, CRC, COC, CPC-I – AHIMA Approved ICD-10-CM/PCS Trainer – bpeters@thinkbrg.com – (505) 918-7551

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References

• “APR-DRGs in the Medicaid Population”, Judy Sturgeon, CCS,

CCDS, For the Record, Vol. 25, No. 5, Pg. 6

http://www.fortherecordmag.com/archives/0313p6.shtml

• “The Evolution of DRGs (Updated)”, American Health Information

Management Association, Journal of AHIMA, April 2010

http://library.ahima.org/xpedio/groups/public/documents/ahima/

bok1_047260.hcsp?dDocName=bok1_047260

• Overview of the 3M™All Patient Refined (APR) DRGS”

http://multimedia.3m.com/mws/media/910941O/ebook-

overview-of-the-3m-apr-drgs-10-

13.pdf?fn=3M_APR_DRG_eBook.pdf

References

• PEPPER Short-term Acute Care Program for Evaluating Payment

Patterns Electronic Report, User’s Guide Nineteenth Edition

https://www.pepperresources.org/

• Office of Inspector General Work Plan Fiscal Year 2016

http://oig.hhs.gov/reports-and-

publications/archives/workplan/2016/oig-work-plan-2016.pdf