an ‘outside the box’ case study: how clinical ... · how clinical documentation helped baptist...

© 2017 Nuance Communications, Inc. All rights reserved. 1© 2017 Nuance Communications, Inc. All rights reserved. 1

An ‘Outside the Box’ Case Study: How Clinical Documentation Helped Baptist Health Realize Improved Financial Performance

Lorena S. Chicoye, MD

Corporate Medical Director

Baptist Health South Florida

813-546-4846

[email protected]

Mel Tully, MSN, CCDS, CDIP

VP Clinical Services & Education

Nuance Communications, Inc.

678-999-3262

[email protected]

© 2017 Nuance Communications, Inc. All rights reserved. 2

Agenda

– Objectives

– Advanced Practice Clinical Documentation Improvement

Industry Current State, Technologies, Challenges

– Baptist Health South Florida Use Case: How Clinical

Documentation Helped Baptist Health Realize Improved

Financial Performance

– Best Practices

– Questions & Answers


Objectives

– Learn the implementation process of a clinical

documentation improvement program

– Identify both successes and failures of Baptist Health South

Florida unique structure

– Identify the best tracking metrics for a successful

documentation program

– Learn the best ways of communicating with physicians


Shift to Advanced Practice CDI

Clinically focused, quality-based

Physician engagement

Pivot to CDI technology embedded in EMR

– Artificial Intelligence, NLP, Machine Learning

– CAPD

– CACDI

Ambulatory CDI


Documentation

Errors that Can

Cost Millions …

$$$


Clinical Documentation ChallengesUp to 1 out of 5 claims may be denied due to inadequate clinical documentation and lack of medical

necessity, costing between 2 percent and 5 percent of net patient revenue.* For an average 300-

bed organization, 1 percent of net patient revenue can equate to $2 million to $3 million annually.**

Claims that did not meet Medicare requirements **

Error Category Percent of 2016 National Improper Payment Rate

2016 Projected Improper Payments ($B)

No Documentation

1.3% $0.5

Insufficient Documentation

65.2% $26.8

Medical Necessity

19.8% $8.1

Incorrect Coding

10.2% $4.2

Other 3.5% $1.4

* GE Healthcare

** 4 ways healthcare

organizations can reduce claim

denials,” by Kelly Gooch,

Becker’s Hospital CFO, 7-26-16,

*** Medicare Fee-for-Service

2016 Improper Payments Report


Steady shift toward risk-based payment

Medicare value-based purchasing program performance criteria

Source: CMS.gov

2018*2017201620152014

25%20% 25% 25% 25%

30%

45%

30%

30%

20%

40%

25%

10%

25%

25%

25%

25%

25%

5%

20%

Safety Process of Care Experience of Care* Outcomes of Care Efficiency of Care*

Process %

Decreases

Over Time

Safety

New Domain

2017 & 2018


6%Medicare revenue at risk from mandatory

pay-for-performance programs, FY 2017

Includes Value-Based Purchasing Program, Hospital Readmissions Reduction Program,

and Hospital-Acquired Conditions Program.


Which documentation is better?

1. 79 YO Female Patient who presents with a left lower lobe pneumonia. On presentation patient

was found to have an elevated WBC count of 19,000 with left shift, respiratory rate of 24, HR of

110 and Temp of 102.5 F, Blood Pressure of 90/40 and altered mental status. Patient admitted

to ICU, Vasopressors if needed, Blood Cultures. Improving on IV Fluids and broad spectrum

antibiotics.

or

2. 79 YO Female patient who presents with a left lower lobe pneumonia,

sepsis and septic encephalopathy, transferred to ICU improving with

treatment.

Expected Mortality 11.7%

Expected Mortality 1.0%


50th Percentile

Hospitals with clinically-focused CDI outperform their peers in overall mortality ratings

90th Percentile 75th Percentile

of Nuance CDI Client Hospitals are in the

50th percentile for overall mortality ratings 93%



Who are we?

Baptist Health South Florida is a 9 hospital system in

Miami/Dade, Palm Beach and Monroe Counties. Our

hospitals service a large Caribbean and Latin community.

We also have a large international presence throughout

the Caribbean. Many of our practicing physicians are

from these areas.


Why Clinical Documentation Improvement Program in 2008

– Impending ICD-10

– Compliance

– Quality

– Economic Impact

– Impending EHR


ICD-10

– Start physicians with a program in ICD-9 to “soften the blow” of

ICD-10

– Start education of ICD-10 in conjunction with ICD-9 for all clinical

personnel and HIM

– Minimize disruption of hospital process and reimbursement

secondary to ICD-10 implementation and EHR implementation.


Compliance

CMS expects physicians to document

diagnosis and procedure codes to the

greatest level of specificity

NOT UPCODING


Quality

Publically reported data:

– Health Grades

– Hospital Compare

– Physician Compare

– MyUHC.com

– US News and World Report

– JCAHO

– CMS.gov


Economic Impact

– MS-DRG

– Comorbidities and Complications (CC)

– Major Comorbidities and Complications(MCC)

– APR-DRG

– Severity of Illness (SOI)

– Risk of Mortality (ROM)

– Appeals/Denials



Philosophy and Approach to Correct Coding and

Documentation

– Conservative Organization

– 9 year history of having physicians reviewing charts

referred by HIM for retro queries prior to CDI

implementation in 2011

– Need to expand the program


Correct Coding and Documentation

Key Personnel

• Corporate Directors

-- CEO’s, CFO’s, COO’s

-- Medical Directors, VPMAs

-- HIM Director

-- Managed Care Vice President

-- IT Director

-- Patient Financial Services Director

-- Corporate Director of Care Management


Correct Coding and Documentation

Technology Tools

• RFP process looking for:

-- Case mix improvement

-- Higher quality scores

-- Audit protection/RAC

-- Increased reimbursement

-- Tools easy to use

-- Training of CDI’s and HIM

-- Evaluation and re-evaluation**


Vendor Selected Nuance/J.A. Thomas (JATA)

Chose a vendor whose only business was clinical

documentation improvement

– In business for 20 years

– Proven track record

– Guaranteed return on investment if followed their process


Program Implementation

– Determination of targeted population– Traditional Medicare

– Non-Contracted Medicare

– Contracted Medicare Advantage DRG payers

– Medicaid 2018

– Full House Review 2019

– Out Patient CDI

– Assessment and review of charts on-site of 5 hospitals to

determine documentation opportunities

– Steering Committees for each hospital set up– Hospital Leadership

– Key physicians

– HIM

– Case Management


Program Implementation

– HIM implementing software and links to

Nuance/JATA

– Now EHR/Cerner


Hiring Clinical Documentation Improvement Specialists

– One CDI specialist for each 1,800 Medicare Discharges

– Nuance/JATA did not recommend retired or actively practicing physicians

functioning in this role BUT

We recognized early on that we had a highly educated group of

physicians whose medical knowledge was being underutilized.

These international physicians were waiting for acceptance into

residency program in the US. While waiting, they took jobs that did

not either recognize nor utilize their medical knowledge.

– Required passing of JATA general internal medicine exam

– Passing scores of the ECFMG (Educational Commission for Foreign

Medical Graduates) a plus


Communication and Education

Implementation

– Nuance/JATA provided physician experts to speak at medical staff

meetings

– Introduced program and CDI specialists to all departments during

department meetings. CDI specialists were introduced as

physicians with MD on badges

– During meetings explained goals and objectives of program along

with physician and hospital data and competitors

– General and facility specific documentation issues

– Shared benefits to the physicians and hospitals

– The programs tracking capabilities


Communicating with Physicians

– Face to face

– Text/Phone

– Fax

– Electronic health records

– Newsletters

– Department meetings

– Computer screens

– Baptist Health University


Clinical Documentation Management Program

CDI Miami


CDI Miami Staff

– Freddy Bowen, MD

– Glayser Cossio Corral, MD

– Katia Jimenez, MD

– Luis Lasose-Cabrera, MD

– Maria Carralero, MD

– Marie-Guilene Alfred, MD

– Marina Matute Obispo, MD

– Mark Zaki, MD

– Mayje Otero Zubizarreta, MD

– Neida Merida, MD

– Okey Adele, MD

– Omar Barreto, MD

– Oscar Lopez, MD

– Tatiana Guerrero, MD

– Teresa Lopez, MD

– Zulema Hernandez, MD

• Melissa Delgado (Administrative Assistant)

• Lorena S. Chicoye, MD

• Gabriel Colon, MD Director


Clinical Documentation Improvement Specialists

The Clinical Documentation Improvement (CDI) Specialist is your liaison between the provider documentation in the medical record and the final coded medical record.

BHSF is the only program in the country that has all international physicians with additional training and certification in clinical documentation (CCDS).


Why CDI?

Your documentation reflects the patient in the bed, the necessity of clinical diagnostics, the severity of the patients illness, the need for continued hospital stay and the quality of care provided.

The final coded record, which is the outcome of your documentation, is shared with CMS, data mining agencies and insurers. The information is used to determine the hospital reimbursement, quality of care, and severity of illness, risk of mortality of the community which is also part of the calculation for physician reimbursement.


Goal

The goal of Clinical Documentation Improvement

team is to make sure the final codes accurately reflect

the complexity and severity of the patient ensuring

accuracy and higher quality of the medical record

along with correct reimbursement.


Determinants of DRG Assignment

– CMS Rules and Regulations

– Coding Clinics

– BHSF HIM Coding Rules

– YOUR DOCUMENTATION


CDMP Quarterly ReportFY 2016 – 4th Qtr. (Jul– Sept) Traditional Medicare

BHM (Implmnt 10/2011) DH (Implmnt 7/2012) HH (Implmnt 5/2012) SMH (Implmnt 10/2011) WKBH (Implmnt 5/2012)

CDMP Activity (JATA Benchmark >

80%)

4th Qt YTD (FY 2016) 4th Qt YTD (FY

2016)

4th Qt YTD (FY

2016)

4th Qt YTD (FY 2016) 4th Qt YTD (FY

2016)

Total Medicare Discharges 1444 6358 468 2241 410 1477 697 3153 331 1714

CDI Reviews 1316 5521 424 2090 410 1346 677 2906 318 1586

CDI Review Rate % 90.1% 86.4% 90.6% 93.7% 100% 94.52% 97.3% 92.5% 97.3% 93.2%

Severity Clarification Rate

Severity Clarification Rate % > 38.1 42.6% 47.2% 27% 31% 40.4% 42.81% 36.7% 39.3% 45.3% 43.2%

Physician - CDI Activity (JATA

Benchmark > 80%)

Response to CDI % 96.9% 94.3% 96% 88% 98.8% 97% 95% 93.9% 96.5% 89%

Agreement with CDI % 81.0% 83.2% 85% 82% 83.0% 81% 75.2% 79.1% 94.5% 90%

Case Mix Index

Baseline Combined CMI 1.56 1.32 1.22 1.58 1.22

Goal CMI 1.67 1.42 1.30 1.68 No

Assessment

New Hospital

Reported CMI 1.9279 1.8866 1.4867 1.4830 1.4782 1.5080 1.8007 1.7905 1.5344 1.5051

Baseline Medical CMI 1.18 1.02 1.06 1.12 No

Assessment

New Hospital

Medical CMI 1.3656 1.3709 1.1219 1.1652 1.2608 1.2401 1.2433 1.2518 1.2753 1.2926

Baseline Surgical CMI 2.64 2.24 2.18 2.38 No

Assessment

New Hospital

Surgical CMI 3.3999 3.3467 2.8516 2.6322 2.6280 2.0622 3.0072 3.0038 2.8349 2.7942

Financial Impact

DRG Reimbursement W/O CDMP $748,924.57 $3,983,796.48 $125,069.76 $877,221.95 $393,104.30 $1,898,134.05 $291,431.05 $1,758,519.03 $213,462.40 $1,022,266.64

DRG Reimbursement with CDMP $1,241,574.22 $6,671,231.55 $198,228.66 $1,466,430.72 $692,661.37 $3,044,921.99 $484,423.23 $2,960,465.54 $348,022.61 $1,632,783.93

Quarterly Improvement $492,649.66 $2,657,110.69 $73,158.90 $589,208.77 $299,557.07 $1,149,742.65 $192,992.18 $1,201,946.51 $34,560.20 $610,517.29


FY 2016 CMI Analysis Medicare

Facility Baseline

CMI

Medicare FY

2016

Oct 2015 to

Sep 2016

Predicted

CMI

Predicted

CMI

Improvement

Actual % FY

2016

Improvement

BHM 1.56 1.9144 1.67 7% 23%

SMH 1.58 1.8007 1.69 7% 14%

DH 1.32 1.4867 1.42 7.6% 13%

HH 1.22 1.4578 1.32 7% 19%

WKBH 1.22 1.5865 no

assessment

no assessment 30%


SMH – SOI & ROM of 4-ExtremeTraditional Medicare

5.9%

7.0%

8.3%

8.9%8.5%

6.1%

7.5%

9.4%

9.9%

9.4%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

2011 2012 2013 2014 2015

ROM

SOI


SMH – SOI & ROM of 4-ExtremeContracted & NC Managed Medicare

1.4%1.5%

2.1% 2.1%

2.6%

2.0%2.1%

2.8%2.8%

3.4%

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

2011 2012 2013 2014 2015

ROMSOI


Success and Failures

SUCCESSES

– ROI < 6 months

– Increased SOI/ROM

– No RAC pulls for reviewed

charts

– Physician to physician

communication high level

medical discussions

– Training and teaching of

medicine to coders

– Invitations to sit on clinical

committees to ensure

compliant/billable

documentation

FAILURES

– Resistance, initially to

international physicians

– Difficult reaching admitting

privates

– Still some physician

misunderstanding about

program

– Issues with EHR


Success

– National recognition

– Award winning

– Site visits from other hospitals

– Residency programs raiding my team

– Health plans requesting our assistance in the physicians

offices to increase the HCC’s and Star Ratings on risk

contracts


Pivot to technology

– CDI w/AI embedded in EMR

Building a quality based CDI program

– PSI

– Sepsis core measure

– Quality Risk Adjustment

CDI best practice evolution


Initial by physician


Diagnoses


Shared Space


Sample of Missed Coding


Clarification Query


– We use only physicians as CDI specialists due to higher levels of

clinical knowledge over multiple specialties

– Although we are on EHR, we still use face to face as our primary

communication and education of the physicians

– We are cross trained in utilization in order for us to hand off patients

as necessary to case management

– We work daily with HIM to reconcile, teach and be taught by our

coders

– We provide our physician groups with their personal stats and how

this effects them both personally and as a community

– Each hospitals CDI team is responsible for providing educational

sessions on documentation to all stakeholders.

Uniqueness of Our CDI Program


Resources

– Centers for Medicare and Medicaid

– AHIMA

– Baptist University

– Specialty Societies

– www.icd10codesearch.com


QUESTIONS?

Thank you!

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