introduction value-based purchasing claims … measurement source mortality ami chf pna claims the...
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Enhance the Value of Your CDI Program Under Value-Based Purchasing
FTI Consulting, Inc.:Shannon Newell, RHIA, CCS, AHIMA-Approved ICD-10-CM/PCS Trainer; Director
Andrew Rothschild, MD, MS, MPH, FAAP, CCDS, CDIS, AHIMA-Approved ICD-10-CM/PCS Trainer (*Recertifying/credentialing); Director
Purchasing
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Introduction Value-Based Purchasing
Outcomes Measurement SourceMortality AMI
CHFPNA
Claims
The “Outcomes Domain” of Hospital Value-Based Purchasing comprises 30% of performance. The mortality and PSI (patient safety indicator) metrics are derived from ICD-9-CM codes submitted on claims.
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PNA
Serious Complications PSI #90* Claims
CLABSI CDC
*The composite measure which consists of following PSIs:#3 (pressure ulcer)#6 (iatrogenic pneumothorax)#7 (CLABSI)#8 (postop hip fx)#9 (postop hemorrhage or hematoma rate)*#10 (postop physiologic and metabolic derangement)*#11 (postop respiratory failure rate)*#12 (postop PE or DVT)#13 (postop sepsis)#14 (postop wound dehiscence)#15 (accidental puncture or laceration)*Not NQF endorsed
IntroductionClaims-Based Value Initiatives
Clinical documentation improvement programs can impact claims-based metrics
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IntroductionClaims-Based Value Initiatives
The train has left the station … claims-based value initiatives continue to grow:• Value-Based Purchasing Program (VBPP)• Hospital Readmission Reduction Program (HRRP)• Hospital-Acquired Conditions (HAC)
VBPP HRRP HAC Total
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VBPP1.5%
VBPP1.75%
VBPP2%
HRRP3%
HAC1%
HRRP3%
HAC1%
HRRP3%
HAC1%
Total5.5%
Total5.75%
Total6%
FY 2015
FY 2016
FY 2017
IntroductionClaims-Based Value Initiatives
A variety of risk adjustment models are utilized for claims-based metrics – CDI programs must become increasingly sophisticated to capture documentation
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Learning Objectives
• Describe CMS claims based metrics included in the Value Based Purchasing Program (VBPP) and the Hospital Readmission Reduction Program (HRRP)
– Data definitions
– Severity/risk adjustment methodologiesy j g
– Resources for further study
• Discuss the impact of readmission, mortality and patient safety indicator outcomes on hospitals
• Use VBPP principles to:
– Chart review strategies and queries
– Performance metrics which measure and guide CDI program efforts
– Projects to systemize documentation capture7
HOSPITAL-ACQUIRED CONDITIONS (HAC) • The Accountable Care Act (ACA) contains language supporting payment
reductions of 1% in 2015 for hospitals with HAC rates in the top quartile (25%) relative to national average1
HACs
• 1 ACA PLAW-111pub148• CMS HAC: http://tinyurl.com/bzkb3ry
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HACs
• HAC data definition specifications are provided on the CMS site
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HAC Fact Sheet: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-payment/HospitalAcqCond/downloads/HACFactsheet.pdf
Readmission & Mortality
Readmission and Mortality Outcomes – CHF, AMI, pneumonia• Financial penalties for excess readmissions (Hospital Readmission Reduction
Program [HRRP]) and mortality rates (Hospital Value-Based Purchasing [HVBP])
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Readmission & Mortality
QualityNet is the “go-to” site for detailed information on readmission and mortality metrics
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Readmission & Mortality
Key sections to review: “Measure Methodology,” “Resources”• “Resources” includes information on SDx which impact risk adjustment• “CC” = Clinical Categories
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Readmission & Mortality
SDx Clinical Category ICD-9-CM Codes Mapped to “CC”
COPD CC 108Renal failure CC 131Diabetes & DM CC 15-20, 120
Key sections to review: “Measure Methodology,” “Resources” (cont.)
40301Mal hyp kid w cr kid V 131Renal Failure40311Ben hyp kid w cr kid V 131Renal Failure40391Hyp kid NOS w cr kid V 131Renal Failure40402Mal hy ht/kd st V w/o hf 131Renal Failure40403Mal hyp ht/kd stg V w hf 131Renal Failure40412Ben hy ht/kd st V w/o hf 131Renal Failure
compMI CC 81
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40412Ben hy ht/kd st V w/o hf 131Renal Failure40413Ben hyp ht/kd stg V w hf 131Renal Failure40492Hy ht/kd NOS st V w/o hf 131Renal Failure40493Hyp ht/kd NOS st V w hf 131Renal Failure5845Ac kidny fail, tubr necr 131Renal Failure5846Ac kidny fail, cort necr 131Renal Failure5847Ac kidny fail, medu necr 131Renal Failure5848Acute kidney failure NEC 131Renal Failure5849Acute kidney failure NOS 131Renal Failure
5851Chro kidney dis stage I 131Renal Failure5852Chro kidney dis stage II 131Renal Failure5853Chr kidney dis stage III 131Renal Failure5854Chr kidney dis stage IV 131Renal Failure5855Chron kidney dis stage V 131Renal Failure5856End stage renal disease 131Renal Failure5859Chronic kidney dis NOS 131Renal Failure586Renal failure NOS 131Renal Failure
75314Polycyst kid-autosom rec 131Renal Failure
Risk adjustment utilizes:• Codes from Part A and Part B claims for the prior 12 months• “Comorbid” codes only if present at the time of the index admission
Readmission & Mortality
Source: QualityNet.org – NQF Specifications Manual for National Hospital Inpatient Quality Measures Discharges 01-01-13 (1Q13) through 12-31-13 (4Q13). QualityNet 14
CHF Risk-Adjusted Mortality
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CHF Risk-Adjusted Readmissions
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CHF Risk-Adjusted Readmissions
• “ACS” is assigned to Clinical Categories 81 and 82 which encompass AMI and unstable angina. Excerpt:
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Case Study
• The risk-adjusted mortality rate for Hospital P’s AMI patients is 50% higher than expected
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Case Study
• 79 yo male with chronic systolic heart failure, CAD, COPD• Presented w/ increased dyspnea, tachypnea, +3 pitting edema,
chest discomfort, cough• EKG unchanged, Q-wave abnormalities c/w prior MIs• Cardiac troponin >99th percentile x1, now decreasingp p g• Echo: RVH, pulmonary artery HTN, LVEF, EF 30%• Nursing: “Coccyx with nonblanchable redness with skin tear x2”• Discharge summary Dx:
1. Exacerbation of systolic HF with troponin leak2. COPD exacerbation
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Case Study Query – NSTEMI
• Query to clarify whether the patient had an NSTEMI• Acute decompensation of chronic systolic HF with a “troponin leak”? or• Acute decompensation of chronic systolic HF with an NSTEMI?
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Were the elevated troponin levels indicative of NSTEMI?
N Engl J Med 2008; 358:2117-2126 May 15, 2008 DOI: 10.1056/NEJMoa0706824 http://www.nejm.org/doi/full/10.1056/NEJMoa0706824
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Case Study Query – NSTEMI
• Troponin elevations in acute heart failure indicate poor prognosis• Especially with ultra-sensitive test, providers (cardiologists) must
indicate clinical significance, or relevance, of results
Outdated
• Peacock, W.F., et. al. Cardiac troponin and outcome in acute heart failure. N Eng J Med 2008;358:2117–2126.
• Horwich, T.B., et. al. Cardiac troponin I is associated with impaired hemodynamics, progressive left ventricular dysfunction, and increased mortality rates in advanced heart failure. Circulation 2003;108:833–838.
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Case Study Query – NSTEMI
• Definition of myocardial infarction—criteria for acute myocardial infarction– Evidence of myocardial necrosis in a clinical setting consistent with acute myocardial
ischaemia
– Any one of the following criteria meets the diagnosis for MI:
• Detection of a rise and/or fall of cardiac biomarker values [preferably cardiac troponin(cTn)] with at least one value above the 99th percentile upper reference limit (URL) and with at least one of the following: g
– Symptoms of ischaemia
– New or presumed new significant ST-segment—T wave (ST—T) changes or new left bundle branch block (LBBB).
– Development of pathological Q waves in the ECG.
– Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality.
– Identification of an intracoronary thrombus by angiography or autopsy.
*Note that four other AMI criteria (outside the scope of this presentation) are defined; and that only one criterion must be satisfied to meet the definition.
Source: Thygesen, K., et al. Circulation 2012;126:2020–2035. 22
Case Study Query – NSTEMI
• AMI can be considered if:– Evidence of myocardial necrosis
(heart muscle cell death)– Clinical scenario consistent with MI– One of five criteria are met from the universal
definition of MI (prior slide)definition of MI (prior slide)• Criterion: Biomarker (e.g., cardiac troponin):
– Should be rising or falling and– Should reach >99th reference percentile and– One of the following is present:
• Symptoms of ischemia• New significant ST changes or new LBBB• Pathological Q waves• Imaging with loss of myocardium or wall motion abnormality• Intracoronary thrombus on angiography or autopsy
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By Cafer Zorkun; Open WikiDoc license: creativecommons.org/licenses/by-sa/3.0
Myocardial necrosis
Case StudyQuery – NSTEMI
• If NSTEMI, is the NSTEMI (or the CHF) the principal diagnosis?
Process Measures AMI-1 Aspirin at ArrivalAMI-2 Aspirin Prescribed at DischargeAMI-3 ACE/ARB Inhibitor
Outcome Measures MORT-30-AMI Acute Myocardial Infarction
(AMI) 30-Day Mortality Rate
MORT-30-HF Heart Failure (HF) AMI-4 Adult Smoking Cessation Advice/CounselingAMI-5 Beta Blocker Prescribed at DischargeAMI-7a Fibrinolytic Therapy Received
Within 30 Minutes of Hospital ArrivalAMI-8a Primary PCI Received Within 90 Minutes of
Hospital ArrivalHF-1 Discharge InstructionsHF-2 Evaluation of LVS FunctionHF-3 ACEI or ARB for LVSDHF-4 Adult Smoking Cessation Advice/Counseling
( )30-Day Mortality Rate
MORT-30-PN Pneumonia (PN) 30-Day Mortality
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ICD-10-CM AMI
• ICD-10-CM impact – documentation requirements for AMI
Documentation Requirement
ICD-9-CM ICD-10-CM/PCS
Type of MI • STEMI (Q wave, transmural),• NSTEMI (non Q wave,
t l b d di l)
Same except unspecified defaults to STEMI
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nontransmural, subendocardial)• Unspecified
Acute MI time frame
Acute = < 8 weeks; considered initial episode of care
Acute = <4 weeks (28 days); episode of care not recognized–just time frame
Subsequent episode of care
Use of treatment provided to AMI after acute time period
Episode of care not recognized–just time frame. If >4 weeks, coded as new acute MI.
Subsequent acute MI
Treated as new acute MI Unique category for second+ acute MI; may be PDx/SDx; must also assign initial AMI code
ICD-10-CM AMI
• ICD-10-CM impact – documentation requirements for AMI (cont.)
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ICD-10-CM AMI
• ICD-10-CM impact – documentation requirements for AMI (cont.)
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ICD-10-CM AMI
• ICD-10-CM acute MI decision tree
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• AMI not further specified as NSTEMI or STEMI defaults to STEMI (Source: ICD-10-CM OCG)• No documentation of time frame defaults to initial (Source: ICD-10-CM Index – duration of <4 weeks
nonessential modifier)• I-10 code exists for initial/subsequent STEMI not further specified re: wall/artery (121.3, 122.9)
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ICD-10-CM AMI
• ICD-10-CM acute MI decision tree (cont.)
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ICD-10-CM AMI
AMI query form – key content:• Time frame since event: __ <28 days (4 weeks) __ < 8 weeks ___Unknown
• Type: STEMI or NSTEMI (unspecified type defaults to STEMI)
• If STEMI, please provide wall site and artery*
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Case Study
• 79 yo male with chronic systolic heart failure, CAD, COPD
• Presented w/ increased dyspnea, tachypnea, +3 pitting edema, chest discomfort, cough
• EKG unchanged, Q-wave abnormalities c/w prior MIs
C di i 99 h il 1 d i• Cardiac troponin >99th percentile x1, now decreasing
• Echo: RVH, pulmonary artery HTN, LVEF, EF 30%
• Nursing: “Coccyx with nonblanchable redness with skin tear x2”
• Discharge summary Dx:
1. Exacerbation of systolic HF with troponin leak
2. COPD exacerbation
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Case StudyQuery – Old MI
• Query to clarify the diagnosis causing the Q-wave abnormalities
Criteria for prior myocardial infarction
Any one of the following criteria meets the diagnosis for prior MI:
P th l i l Q ith ith t t
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Photo by Peter Anderson, DVM, PhD, U. of Alabama at Birmingham, Dept. of Pathology Open WikiDoc license: creativecommons.org/licenses/by-sa/3.0
Myocardial necrosis at site of AMI
Pathological Q waves with or without symptoms in the absence of non-ischemic causes
Imaging evidence of a region of loss of viable myocardium that is thinned and fails to contract, in the absence of a non-ischemic cause
Pathological findings of a prior MI
Copyright American Heart Association
Thygesen, K., et al. Circulation 2012;126:2020–2035.
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AHRQ Quality IndicatorsPSIs & IQIs
Patient Safety Indicators (PSI) and Inpatient Quality Indicators (iqi)• AHRQ: Federal agency for healthcare research – quality, costs, outcomes, patient safety • PSIs focus on potentially avoidable complications and iatrogenic events (adults, hospital)
PSI # 90 is a “composite” metric included in the 2015 VBPP and is comprised of the following PSIs
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p g
*The composite measure which consists of following PSIs:#3 (pressure ulcer)#6 (iatrogenic pneumothorax)#7 (CLABSI)#8 (postop hip fx)#9 (Postop hemorrhage or hematoma rate)#10 (Postop Physiologic and Metabolic Derangement)#11 (Postop Respiratory Failure Rate)#12 (postop PE or DVT)#13 (postop sepsis)#14 (postop wound dehiscence)#15 (accidental puncture or laceration)
AHRQ Quality IndicatorsPSIs & IQIs
• PSI data definitions can be located on the AHRQ website:
34• AHRQ: http://tinyurl.com/3pq7jp8
AHRQ Quality IndicatorsPSIs & IQIs
• An example of a data definition – PSI #13 (Postop Sepsis):
35AHRQ: http://tinyurl.com/3pq7jp8
AHRQ Quality IndicatorsPSIs & IQIs
• Inpatient Quality Indicators (IQI) focus on inpatient mortality for selected conditions and procedures (adults, hospital setting)
IQI #91
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Will be removed in future Hospital Compare updates. Source: CMS Final Rule IPPS 2013.
IQI #19
IQI #15
IQI #16
IQI #17
IQI #18
IQI #29
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AHRQ Quality IndicatorsPSIs & IQIs
IQIs and PSIs use different risk adjustment methodologies:• IQIs utilize the APR-DRG classification system • The PSIs use an AHRQ risk adjustment methodology (below)• AHRQ will move to a single method for all of the QIs in the future
PSI #3 – Pressure Ulcer
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Table 2Definitions of Comorbidities
ICD-9-CM Diagnosis Codes
Discharge Does Not Have these Pre-V29 DRGs
8. Chronic pulmonary disease
490–492.8, 493.00–493.92, 494–494.1, 495.0–505, 506.4
COPD asthma 190–192, 202–203
AHRQ: http://tinyurl.com/accdpd6; http://tinyurl.com/at3jhpkHCUP: http://tinyurl.com/bg4oh2h
AHRQ PSI #90 CompositePSI #3 – Pressure Ulcer
Also a HAC –triple
indemnity?
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* Pressure ulcer stage “unstageable” is included in PSI #3 (not true for HAC)* Pressure ulcer capture is risk adjusted in PSI #3 (not true for HAC)
AHRQ PSI #90 Composite PSI #3 – Pressure Ulcer
Comorbidity Category examples:
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Case Study
• 79 yo male with chronic systolic heart failure, CAD, COPD
• Presented w/ increased dyspnea, tachypnea, +3 pitting edema, chest discomfort, cough
• EKG unchanged, Q-wave abnormalities c/w prior MIs
C di i 99 h il 1 d i• Cardiac troponin >99th percentile x1, now decreasing
• Echo: RVH, pulmonary artery HTN, LVEF, EF 30%
• Nursing: “Coccyx with nonblanchable redness with skin tear x2”
• Discharge summary Dx:
1. Exacerbation of systolic HF with troponin leak
2. COPD exacerbation
40
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Case StudyQuery – Skin Ulcer
• Query for diagnosis reflective of nursing note of “Coccyx with nonblanchable redness with skin tear x2”
– Pressure (decubitus) ulcer?
– Non-pressure skin ulcer?p
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Case StudyQuery – Pressure Ulcer
Stage/Description MS-DRGMCC
HACif not POA
PSI 90
CMSRiskAdjust
Stage 1 – Intact skin w/localized non-blanchable rednessusually over boney prominence
No No No Yes
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Stage 2 – Partial thickness loss of dermis, shallow open ulcerwith a red-pink wound bed or blister
No No No Yes
Stage 3 – Full thickness skin loss. Subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed
Yes Yes Yes Yes
Stage 4 – Full thickness with exposed bone, tendon or muscle Yes Yes Yes Yes
Unstageable – Stage cannot be determined, e.g. eschar, graft No No Yes Yes
Unspecified – Stage not specified No No No Yes
ICD-10-CMPressure Ulcer
• ICD-10-CM skin ulcer decision tree
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Non–Pressure Ulcer SeverityBreakdown of skin*
Fat layer exposed*
Necrosis of muscle*
Necrosis of bone*
Unspecified
*MS-DRGCCs
ICD-10-CMPressure Ulcer
• Skin ulcer sites
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Beyond Case Review Process Flow, Metrics, Projects
Process flow• Scope of concurrent review• Principal diagnosis selection• Secondary conditions to query/code• Query priorities• Query priorities• Complication code assignment• Pre-bill review• Query templates• Post-discharge query follow-up• Admission source• Discharge disposition
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Beyond Case Review Process Flow, Metrics, Projects
• Metrics• Hospital-Specific Report (QualityNet Administrator)
46http://www.qualitynet.org – Hospital-Specific Report
Beyond Case Review Process Flow, Metrics, Projects
• Metrics (cont.)• ARHQ software
47http://www.qualityindicators.ahrq.gov/Software/Default.aspx
Beyond Case Review Process Flow, Metrics, Projects
• Projects• Definitions of terms• Admission/discharge disposition• Synergy with clinical performance
improvement• Documentation templates and/or
care delivery processes• Nutritional services• Skin assessments• Lab results reporting• Problem lists• Preop/anesthesia assessment• Procedure templates• Education
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Resources
• AHQR Toolkit• Designed to promote understanding and use of AHRQ Quality Indicators
(QI) to successfully improve quality and patient safety in hospitals• http://www.ahrq.gov/qual/qitoolkit/qifactsheet.htm
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Resources
• ICD-10-HAC List: http://tinyurl.com/cl3plfx
• AHRQ QI conversion to I-10: http://tinyurl.com/bbxk98x
• AHRQ: http://www.qualityindicators.ahrq.gov
• CMS VBPP/HRRP/HAC/Hospital Compare: http://tinyurl.com/a4zldst
• CMS HRRP: http://tinyurl.com/9kqtob2
• CMS HAC: http://tinyurl.com/az3nkuj
• CMS Hospital Compare: http://tinyurl.com/bxv8urg
• QualityNet: https://www.qualitynet.org
• CMS Inpatient Quality Reporting Program: http://tinyurl.com/akgs2l
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In Summary
• Clinical documentation improvement programs can be a significant contributor to how well your organization performs under various CMS claims-based value initiatives
VBPP1 5%
HRRP3%
HAC1%
Total5 5%FY 2015
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1.5%
VBPP1.75%
VBPP2%
3% 1%
HRRP3%
HAC1%
HRRP3%
HAC1%
5.5%
Total5.75%
Total6%
0 5
FY 2016
FY 2017
In SummaryThe Train Keeps Moving
• Three new claims-based measures on CMS Hospital Compare in 2013 – once posted for 1 year, CMS can elect to include in VBPP1
521http://www.cms.gov/apps/media/press/factsheet.asp?Counter=4422
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In SummaryGet on Board!
• Find out how your organization is performing for claims-based metrics andperforming for claims based metrics and how metric performance is monitored
• Heighten awareness of how clinical documentation can contribute to improvement efforts
• Research metric data definitions,identify areas with documentationand coding vulnerability, roll up your sleeves, and have fun!
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Thank you. Questions?
In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section at the front of the workbook.
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