©2012 THE ADVISORY BOARD COMPANY ADVISORY.COM P ARTNERING WITH P HYSICIANS FOR B EST - IN -C LASS C...

©2012 THE ADVISORY BOARD COMPANY • ADVISORY.COM

PARTNERING WITH PHYSICIANS FOR BEST-IN-CLASS CLINICAL DOCUMENTATION

Presentation to Palmetto Health

September 27th, 2012

WHY WORDS MATTER


DISCLOSURES

I am a consultant for The Advisory Board Company–Joe Corcoran, D.O., F.A.C.O.G

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Road Map for Discussion

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Health Care Transformation – Raising the Stakes on Documentation

Appendix: Deconstructing Provider Documentation Clinical Examples

The Importance of Documentation Quality


All (Reform) Roads Lead to Closer Physician Collaboration All (Reform) Roads Lead to Closer Physician Collaboration

©2012 THE ADVISORY BOARD COMPANY • ADVISORY.COM 5

A Tale of Two Providers

Financial Ethical SocietalLegal Political

Facility and Physician payment administered separately

Physicians in independent practice purchase own liability insurance

Hippocratic oath, the foundation of medical ethics

Charity care obligatory for hospitals, “recommended” for physicians

Facilities and physicians represented by entirely separate professional associations

Physicians must manage their own finances

Physicians bear high costs of premiums, high risk to reputation

Physicians advocate for individual patients, not overall business performance

Physicians rarely reimbursed for charity patients

Physicians fight for own rights and protection

The Physician Stands Alone


Revisiting the Importance of Clinical Documentation

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Clinical documentation has long been recognized as a key opportunity for improving reimbursement capture and safeguarding operating margins. With increasing public reporting and integration of performance metrics into provider reimbursement, the quality risks of poor documentation have become further magnified.

Inaccurate provider profiling Inflated complication rates Poor public reporting results Inaccurate risk of mortality reporting Acuity of patient condition not reflective of

severity of illness Increased risk of unnecessary readmissions Reduced reimbursement & pay for

performance Increased denial rates Greater recovery audit contractor (RAC) risk

Risks of Poor Documentation Performance

Physician and Health System Collaboration is Critical to Success

Source: Laschober M, “Hospital Compare Highlights Potential Challenges in PublicReporting Hospitals,” Issue Brief, Mathematica Policy Research, Inc., March 2006; Clinical Advisory Board interviews and analysis.

Key Outcomes of Improved Documentation

Enhanced Care Coordination through Improved Communication and Patient Transitions

Improved Quality Outcomes and Physician Performance

Improved Ability to Accurately Capture Care Provided and Realize Appropriate Reimbursements


Omissions in Documentation have an Outsized Impact on Reimbursement

1 Systemic inflammatory response syndrome.

Top Five Clinical Documentation Issues

Source: Centers for Medicare and Medicaid, “FY 2012 IPPS Final Rule”, available at: https://www.cms.gov/AcuteInpatientPPS/FR2012/list.asp, accessed February 7th, 2012; Financial Leadership Council interviews and analysis; Clinical Advisory Board interviews and analysis.

The Price of Omission

Condition Common Documentation Issues

Congestive Heart Failure

• Clarification needed (e.g., acute vs. chronic, systolic vs. diastolic)

Sepsis• Often unclear whether sepsis, severe sepsis,

SIRS1, bacteremia, UTI, Urosepsis, etc

Renal Failure• Clarification needed (e.g., acute vs. chronic)• Lack of specificity (renal insufficiency” vs.

“failure,” specify stage of kidney disease)

Pneumonia• Failure to document cause (e.g., causative

organism, aspiration)• Need to specify simple vs. complex

Respiratory Failure

• Clarification needed (e.g., acute vs. chronic)• Lack of specificity (respiratory “distress” vs.

“insufficiency” vs. “failure”)

DRG 682:

(Renal Failure with Major Complications and Co-morbidities)

$9,240.73

DRG 684:

(Renal Failure without Major Complications and Co-morbidities)

$3,609.01

Net Revenue Impact: $5,631.72

Financial Impact

vs.


Unclear Documentation Skews Performance Data

Accurate Quality Performance Hinges on Complete, Clear Documentation

Source: Clinical Advisory Board interviews and analysis. 1) Pseudonym.

Case in Brief: Bayberry Hospital1

• 400-bed hospital located in the Northeast• Realized organization’s complication rates were

significantly skewed by coders reporting complication due to unclear documentation

Complication Rates

• Lack of clear and concise documentation resulting in assignment of complication codes for expected outcomes from surgery

• Improvements in documentation and coding resulted in lowered complication rates across all areas

Reasons for Inflated Complication Rates



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Appendix:Deconstructing Provider Documentation – Clinical Examples



Changing Coding Requirements

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Minimal Physician EducationMed School & Ongoing training minimal

Stretched Thin – Lack of Time

INCOMPLETE DOCUMENTATION

(Majority of Errors)

Examples

Diagnostic tests suggest need for higher

specificity or a secondary diagnosis

HF is documented but echocardiogram results confirm systolic heart failure. Not a MCC

without specification.- or - Urine test indicates low sodium. Physician writes “low sodium” but not hyponatremia; CC

cannot be coded.

Patient being treated for an undocumented

condition

Foley catheter ordered w/o reason. Nurses

document that patient urinates 2 days later.

Evidence supports that patient had post-operative

urinary retention but physician must document

condition for coding.

AMBIGUOUS DOCUMENTATION

(Common)

Examples

Confusion due to grammar and/or handwriting – can affect ID of primary and secondary diagnoses

“Syncope secondary to ischemic colitis and SBO vs.

intestinal abscess”. Is ischemic colitis the principal

diagnosis with syncope secondary – or – is syncope the primary diagnosis & the result of ischemic colitis and

SBO?

Principal diagnosis-the reason for admission, after study-not clearly identified

- or- Not clear whether a condition was ruled out

Patient presents with syncope; MD orders at CT Scan and MRI to rule out

Stroke, and an echo to rule out arrhythmia or heart failure.

Physician must document when/if CVA, arrhythmia or HF have been confirmed or

ruled out.

CONFLICTING DOCUMENTATION

(Least Common)

Examples

Conflicting info from different physicians, e.g. consultant vs. attending

Patient admitted by PCP because of vertigo &

confusion. PCP documents TIA as a

preliminary diagnosis & requests a neurology consult. Neurologist

documents cerebrovascular accident as the diagnosis.

PCP does not further document so info is

conflicting; coder either needs clarification before coding or must default to

PCP diagnosis.

Conflicting info from progress note to

progress note (same physician)

Self explanatory error. Physician must clarify and

add an addendum to discharge summary/final progress note for coding.

Source: March 2009 NPD pull up

Key Drivers of Physician Under-Documentation


Facts: On August 24th, 2012 CMS releases a final rule that would delay ICD-10 compliance until October 1st, 2014.

CMS cites several reasons:•Ongoing transition to Version 5010—a necessary precursor to ICD-10 adoption•Hospitals, health systems, and physicians' current efforts to comply with Meaningful Use Stage 2 requirements•The industry's lack of preparation, as 26% of providers and 28% of payers do not expect to be compliant with ICD-10 by October 1, 2014, according to a recent CMS readiness survey

Regardless of the transition timeline and proposed date, a critical element of ICD-10 preparation is helping physicians to capture key clinical concepts and specificity that will be required in the far more complex environment. This will lead to success in both an ICD-9 and ICD-10 environment.

Looking Ahead: ICD-10 Quick Facts

The ICD-10 Code Set

~69,000ICD-10-CM Codes

~72,000 ICD-10-PCS Codes

New Code Set Breakdown:

50% Percentage of all ICD-10 codes are related to the musculoskeletal system

36% Percentage of all ICD-10-CM codes are related to laterality (distinguishing “right” vs. “left”)

25% Percentage of all ICD-10 codes are related to fractures

ICD-10 Facts

• ICD-10 CM (clinical modification) diagnosis codes have been adopted for institutional, outpatient and professional services

• ICD-10 PCS (procedure coding system) procedure codes are used for inpatient

• Claims will not be accepted in ICD-9 format after the compliance date

• Compliance date applies to the date of service for outpatient and professional claims, and date of discharge for institutional claims

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All (Reform) Roads Lead to Closer Physician Collaboration Impact Spans the Hospital and Physician Practice

• Additional clinical details must be noted

• Additional requests from coders attempting to enter procedures and diagnoses into information systems

• Additional requests from documentation improvement staff

Documentation

Queries

Hospital: Coding Challenges

Potential physician workflow disruption

derive from new documentation

requirements and increased query volumes that may exist to facilitate

code assignment.

Addressing Documentation and Query Impacts


Quality Measures Impacted by ICD-10

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Acute Myocardial Infarction Example

• Codes related to the cardiovascular system account for the number one primary code set for inpatient admissions based on charged amount

• Acute myocardial infarction is a significant event related to patient care morbidity and mortality

• Key measures of quality depend on the definition of an acute myocardial infarction at the timing of the encounter

Definition of Acute Myocardial Infarction (MI) has Changed

Subsequent vs. Initial Episode of Care

Subsequent (MI)

• ICD-9: Eight weeks from initial onset

• ICD-10: Four weeks from initial onset

• ICD-9: Fifth character defines initial vs. subsequent episode of care

• ICD-10: No ability to distinguish initial vs. subsequent episode of care

• ICD-9: No ability to relate a subsequent MI to an initial MI

• ICD-10: Separate category to define a subsequent MI occurring within 4 weeks of an initial MI

Source: Health Data Consulting13


Re-capping the Advantages of Better Clinical Documentation

• Greater detail or reported condition• Greater granularity allows for categorization

of conditions and procedures• Greater severity and risk definition• Code design allows for greater flexibility for

modification in the future • Greater ability to integrate clinical

information

• COMPLIANCE• More appropriate contracting• More appropriate payment• Better fraud, waste and abuse detection• An opportunity to differentiate from less

prepared competitors

• Improved measurement of quality, efficiency and outcome measures

• Greater detail incorporates attributes related to severity, risks, co-morbidities and classifications that help distinguish major differences in conditions

• Enhanced network management with the ability to look at network adequacy for regional patterns of diseases

Better Information Better Indication of

Severity & Risk Better Business


Engagement Team

Please do not hesitate to contact your team with any questions or comments.

Joe Corcoran, DO, FACOGSenior Director

[email protected]

Robert M. LinnanderPartner

[email protected]

Ben Beadle-RybyProject Consultant

[email protected]



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Appendix: Deconstructing Provider Documentation –Clinical Examples



Patient is Admitted with Abdominal Pain Through the ED

A patient is admitted through the emergency department (ED) after presenting with undiagnosed abdominal pain. While not optimal, this single symptom has a corresponding ICD-9 code (789.00), which would result in DRG 392, with a reimbursement at a representative hospital of $5,008. Further testing, however, reveals that the abdominal pain is the result of acute cholecystitis (ICD-9 575.10); this would result in DRG 446 (disorders of the biliary tract without complication), which is reimbursed $5,175. The CDI specialist notes an increased creatinine and a decreased glomerular filtration rate and queries the physician regarding the patient’s renal status. If the doctor provides proper documentation, it could be possible to assign a complication for Stage IV chronic kidney disease (ICD-9 585.4), which would result in DRG 445 (disorders of the biliary tract with CC), reimbursed a total of $7,464. The patient undergoes a laparoscopic cholecystectomy (ICD-9 51.23), changing the DRG to 418 (laparoscopic cholecystectomy with CC), with a resulting reimbursement of $11,868. Next, the patient develops shortness of breath, and the consulting cardiologist documents acute-on-chronic systolic heart failure (ICD-9 428.23), changing the DRG to 417 (laparoscopic cholecystectomy with MCC) with a resulting reimbursement of $17,478.

Clinical Example #1

Summary of Hospital Stay and Financial Impact

Hospital Course Developing Signs and Symptoms ICD-9 Code

DRG Potential Reimbursement

History of Present Illness

A patient is admitted through the ED after presenting with undiagnosed abdominal pain

789.0 392 $5,008

Imaging Further testing reveals that the abdominal pain is the result of acute cholecystitis

575.10 446 (disorders of the biliary tract without complication)

$5,175

Laboratory • The CDIS notes an increased creatinine and a decreased GFR and queries the physician regarding the patient’s renal status

• If the physician provides proper documentation, it could be possible to assign a complication for Stage IV chronic renal disease

585.4 445 (disorders of the biliary tract with CC)

$7,464

Surgery Patient undergoes a laparoscopic cholecystectomy

51.23 418 (laparoscopic cholecystectomy with CC)

$11,868

Complications • Patient develops shortness of breath

• Cardiologist documents acute on chronic congestive heart failure

• Systolic dysfunction present

428.23 417 (laparoscopic cholecystectomy with MCC)

$17,478

Net Revenue Impact $12,470


Assessing the Completeness of Sepsis Documentation

Clinical Example #2

Clinical Decision Making Documentation Requirement

Is there a non-infectious process (e.g. burns, serious injury/trauma) being treated this stay?

State the non-infectious process

Is there a local infectious process (e.g., UTI, pneumonia, decubitus ulcer) being treated this stay?

State the infectious process

What is the cause of the local infectious process (e.g. causative organism - klebsielia, e.coli)?

State the causative organism

Does the patient have SIRS/septicemia/ sepsis/severe sepsis?

State the sepsis level

Is there an underlying condition that is the cause of the sepsis?

State the underlying condition (e.g, organism, local infectious/non-infectious process)

Is there organ failure? List each organ that is in failure

What is the cause of the organ failure (e.g., sepsis, noninfectious process, infectious process)?

State the cause of the organ failure, by organ

Providers in health systems across the country have struggled to provide complete and timely sepsis documentation. As providers complete their clinical decision making process, documentation specialists and EMR templates should prompt providers to provide the most specific clinical information in the patient record.


Clinical Example #3

Preparing for October 1, 2014… The Transition from ICD-9 to ICD-10

• Code structure is 3-5 numeric characters

• Code data (despite known limitations) is the basis for patient care improvement, quality reviews, medical research and reimbursement

• Code structure is 3-5 numeric characters

• Code data (despite known limitations) is the basis for patient care improvement, quality reviews, medical research and reimbursement

ICD-9

• Code structure is 3-7 alphanumeric characters

• Specific diagnosis and treatment information better supports quality and patient safety measurement, the evaluation of medical processes and outcomes, and reimbursement for services rendered

• Precise codes to differentiate body parts, surgical approaches, and devices used

• Code structure is 3-7 alphanumeric characters

• Specific diagnosis and treatment information better supports quality and patient safety measurement, the evaluation of medical processes and outcomes, and reimbursement for services rendered

• Precise codes to differentiate body parts, surgical approaches, and devices used

ICD-10ICD-10-CM

Pressure Ulcer Codes• 125 codes• Show more specific location as well

as depth, including L89.131 – Pressure ulcer of

right lower back, stage I L89.132 – Pressure ulcer of

right lower back, stage II L89.133 – Pressure ulcer of

right lower back, stage III L89.134 – Pressure ulcer of

right lower back, stage IV and many more…..

ICD-9-CMPressure Ulcer Codes

• 9 location codes (707.00 – 707.09)• Show broad location, but not depth

(stage)

On October 1, 2014, the United States will join most developed nations by adopting the International Classification of Diseases – 10th Edition (ICD-10). ICD-10 CM codes are used by all providers to document the diagnoses of a patient. ICD-10 PCS codes are used by hospitals to document inpatient procedures. In summary, the industry is moving from approximately 18,000 codes to 150,000 codes.

Each character in an ICD-10 code represents a unique clinical concept associated with the patient. Therefore, documentation in the record must be complete to support accurate code assignment. If documentation is incomplete, physicians may be queried to provide additional information in the patient record.


No Longer Able to Use the “Old Favorite” Diagnosis Codes in the Clinic or Physician Practice Setting

Clinical Example #4

ICD-9 ICD-10

250.02 Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled

E11.65 Type 2 diabetes mellitus with hyperglycemia

250.43 Diabetes with renal manifestations, type I [juvenile type], uncontrolled

E10.21 Type I diabetes mellitus with diabetic nephropathy AND

E10.65 Type I diabetes mellitus with hyperglycemia

Well… Not Exactly…

“Not much will change. I use 250.0_ for diabetes in my office now. In the future, I will still use 250.0_ I will just need to add more information in the record to support it”

VPMA

300+ bed facility”

Required ICD-10 Concepts: Controlled vs. Uncontrolled, Type, Clinical Details of Disease Manifestation, Pregnancy, etc.

The “old favorite” diagnosis codes used by physicians in their clinics/practices will cease to exist after October 1, 2014. Health systems must partner together to ensure the EMR is able to guide physicians through the documentation and coding process. Further, paper cheat sheets and “super bills” will need to be revised to account for the coding change.


Analysis conducted using the Advisory Board’s ICD-10 Compass technology identified the following 9 documentation issues as most relevant to cardiologists. Relevancy was determined by assessing diagnosis volume, identifying conditions that will require new or more specific documentation in an ICD-10 coding environment, and identifying issues where the absence of unique ICD-10 documentation was clinically relevant.

Source: Advisory Board Analysis; ICD-10 Compass analysis.

ICD-9 Code: Condition: Documentation Issue:

410.00-410.99 Myocardial Infarction Identify whether ST elevation was involved and specific coronary artery associated with infarct.

425.4 Cardiomyopathy Sub-type. Identify whether dilated versus restrictive

423.9 Pericardial Disease Clarify effusion status.

427.1 Ventricular Tachycardia Re-entry variant status. Identify whether ‘re-entry’ type was documented

424.1 Aortic Valve Disorder Clarify type. I.e., Stenosis, insufficiency, regurgitation

424.0 Mitral Valve Disorder Clarify type. Stenosis, insufficiency, regurgitation

427.5 Cardiac Arrest Etiology. Depending upon whether or not the underlying reason for the cardiac arrest is known and if known, whether it is due to cardiac disease may significantly influence patient care and can also influence severity of illness considerations.

997.1 Cardiac Complications Type and Episode of Care. Several cardiac complications previously reported using a ‘catch-all’ complication code are now captured using specific ICD-10 codes (e.g., cardiac arrest, functional disturbance. Relevant cases will be reviewed to determine the nature of the complication and the episode of care involved (e.g. intraoperative vs. postoperative).

427.81 Bradycardia Sick sinus Syndrome status. Identify whether ‘sick sinus syndrome’ was documented

428.0 Congestive Heart Failure Identify the severity of the CHF. Document the acuity (acute, chronic, exacerbation) and dysfunction (systolic, diastolic, combined) of the CHF

Clinical Example #5: Key Clinical Documentation Issues for Cardiologists


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