“The Odyssey of Physician Documentation and CDI: The ... · “The Odyssey of Physician...

March 22, 2017HFMA FL Regional Education Event

“The Odyssey of Physician Documentation and CDI: The Journey

Continues”

Background Information

Physician Documentation and CDI: Past, Present Future

Q & A

Agenda

2

3Proprietary and Confidential. Do not distribute.

Objective

• At the completion of this presentation, the learner will :

• Understand what a successful Clinical Documentation Improvement Program

is and who is involved

• Recognize the impact that physician clinical documentation has on all claims

data

• Review the focus of clinical documentation; past, present and future

• Identify the expanding role of a Clinical Documentation Specialist in various

settings

Background Information


Word of the Day

Odyssey-noun

1 : a long wandering or voyage usually marked by many

changes of fortune

2 : an intellectual or spiritual wandering or quest

Merriam-Webster.com. Merriam-Webster, n.d. Web. 8 Mar. 2017.

Documentation is the beginning, not the end…


The Physician Journey

• Endures many years of education to practice medicine, perform surgery, write

orders and treat patients

• Trained to anticipate all possible negative outcomes

• Create differential diagnoses

• As they become expert, their thinking becomes much quicker and documentation

can often become more generic and/or sparse

• Experienced physicians do not typically document all conditions and outcomes

they are considering (although they think it)

“We think in generalities, but we LIVE in details!”

-Alfred North Whitehead, mathematician & philosopher ( 1861-1947)

If documentation is not correct, the code assignment won’t be correct


Documentation

• If you didn’t document it, it wasn’t done,…or

• If it isn’t documented, it did not happen,…or

• Just because it wasn't documented, doesn't mean it didn't happen.

• If it is documented, it’s important to ask “is it also correct?”

• This is why we have Clinical Documentation Improvement Programs

– Clinical Documentation Improvement ( CDI) is a process used in a variety of settings

by employees who review clinical documentation and provide feedback to physicians

regarding ambiguous information. The feedback is designed to fill in gaps in

documentation so that clear and concise information is available for code assignment,

quality measures, and overall patient care.


Top Four Current Documentation Disasters

• Mixed messages from a physician either through misunderstood dictation or

illegible documentation

• Misuse of copy and paste or copy forward functions in EMR

• Incomplete or missing documentation

• Misplaced documentation


What is a Clinical Documentation Improvement Program?

A CDI program is a comprehensive, multi-disciplinary, hospital-wide

effort to incorporate the terminology needed to accurately translate a

patient's condition into precise codes.

CDI helps ensure the medical record is:

• Complete

• Accurate

• Specific

• Utilizes terms recognized to reflect patient acuity, severity of

illness (SOI), and risk of mortality (ROM)

Normally, this is done on an inpatient concurrent basis

*Ambulatory/Outpatient CDI programs are now evolving

Today, more than 80% of U.S. acute care hospitals have established CDI

programs


Who makes up a successful CDI Program?

Involvement of the key players is crucial to the success of any CDI program

• CDI team includes:

– Executive Leadership

– Clinical Documentation Specialists (CDS)

– Inpatient Coders

– Physician Champion

– Providers/Clinicians


The Importance of Provider Feedback

• What are some of the recurring coding and documentation issues specific to

ICD‐10‐CM/PCS that you have observed to be problematic in terms of

capturing case mix and risk adjustment of your patient population?

• What motivates physicians to document?

• What new concepts should we be relating to physicians to motivate them to

provide the documentation needed?

• What are some ways we can enhance the level of cooperation with our medical

staff?


What Do Providers Care About?

• Reputation

• Mortality data

• How they compare to other docs

• Specialty‐specific diagnoses

• SHOW ME THE DATA!


What Motivates Providers?

• Payment

-CPT documentation, E & M coding….

• Time (convenience)

• Outcomes (patient safety indicators; mortality rates)

• Profiles


The Impact of Clinical Documentation

• Documentation determines coding

• Coding determines:

‾ Payment

‾ Quality metrics

‾ Resource utilization metrics

‾ Risk adjustment of cases

‾ Pay for Performance

‾ Medical necessity


Provider Views of Queries

• Query process

• “Timing of the query creates an issue for me”

• “Structure of the query is such that I am not sure I know how to respond”

• “Too many queries and I do not see the relevance”

• “Some queries are for diagnoses that are not clinically supported or

significant”

• “I am being queried for documentation that I have already stated in the record

Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.

Situations Warranting a Query

The following situations warrant a query:

• Clinical indicators of a DX, but no documentation of a condition

– Hyponatremia, Acute Renal Failure, Malnutrition

• Clinical evidence for a higher degree of specificity or severity

– CHF, Respiratory Failure, CKD

• A cause-and-effect relationship between two conditions or organisms

– UTI d/t E.Coli, UTI d/t Foley catheter, Neuropathy d/t DM

• An “underlying cause” when admitted with symptoms

– AMI with chest pain, Encephalopathy with AMS, Diverticulosis with Abd Pain

• Only the treatment is documented, but not the associated diagnosis

– KCl for Hypokalemia, ABX for ? Infection, PRBC’s for anemia

• Present on admission (POA) indicator status for a documented diagnosis

– Sepsis, PNA, UTI, UTI with Foley catheter

• 2008 American Health Information Management Association (AHIMA) practice brief “Managing an Effective Query Process

16

http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_040394.hcsp?dDocName=bok1_040394

Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.

Additional Reasons To Query

A query is recommended when the following are affected in the inpatient setting:

• Principal diagnosis (affects DRG)

• Procedures that affect reimbursement (affects DRG)

• Discharge disposition (can affect DRG)

• MCCs and CCs (can affect DRG; also important on their own as severity measures)

• HACs (Hospital Acquired Conditions)

• POA (Present on Admission) status

17


Impact of a Query Response

87-year-old female who presented to an outlying emergency department with abdominal pain

and found to have gallstone pancreatitis.

PMH: CHF, CKD, HTN, HLD, DM2, TIA, pancreatitis and diverticulitis

Query

Opportunity

Clinical

Indicators

Impact

CHF, AKI, CKD stage

•CHF--h/o CHF, PN: 7/7-echo shows preserve EF, get BNP, decrease IVF to 70 ml/hr. And

give Lasix 40, close monitoring

•Progress Note 7/9 h/o CHF, noted pleural effusion ( moderate) difficult situation, needs fluid

for pancreatitis and Lasix for CHF, ( decrease IV fluids as pt. developing CHF )

•AKI-AKI could be related to post op dehydration, d/c Lasix, continue IV fluids and monitor

creatinine

•CKD (? Stage)-GFR 29 on admission, creatinine 1.9 on admission, h/o CKD, gently hydrate

Original DRG: 418

Lap Chole w/o CDE with

CC

New DRG: 417

Lap Chole w/o CDE w

MCC

Impact

GMLOS 3.9 5.8 + 1.9 days

RW 1.6.4990 2.3944 + 0.7445

$ $11,259.73 $16,038.18 +$4778.45

SOI/ROM 2/3 3/3

The Past


The CDIP Journey begins…

• DRG- Diagnosis Related Groups-A classification system that groups patients according

to diagnosis, type of treatment, age, and other relevant criteria. Under the prospective

payment system, hospitals are paid a set fee for treating patients in a single DRG

category, regardless of the actual cost of care for the individual

• Diagnostic related group design and development began in the late sixties at Yale

University to create a framework for monitoring quality of care and utilization of services

in a hospital setting

• In 1982, the Tax Equity and Fiscal Responsibility Act modified the Section 223 Medicare

hospital reimbursement limits to include case mix adjustment based on DRGs

• In 1983 Congress amended the Social Security Act to include a national DRG-based

hospital prospective payment system for all Medicare patients

• A new DRG system, called Medicare Severity DRGs (MS-DRGs), was adopted for use

with Medicare’s Inpatient Prospective Payment System, effective October 1 , 2007

– A major driver for many hospitals to invest in CDI programs began as a leading edge

experiment around this time


Coding Capture through MS-DRGs

• MS-DRG- Medicare Severity-Diagnosis Related Groups is a severity-based

patient classification system used in hospital reimbursement

• Principal Diagnosis (Pdx)

• Secondary Diagnosis

• Principal Procedures

• Secondary procedures

– CC, MCC, no CC/MCC

• LOS

– GMLOS, ALOS

• Relative Weights

-Principal DX &

Secondary Dx

-Principal &

Secondary Procedure

Physician

Documentation in

the Medical Record

the

Translates to ICD-10

Codes

Encoder for DRG

Assignment

DRG


Acronyms Associated with MS-DRG’s

• LOS- Length of Stay- duration of a single episode of Hospitalization

– GMLOS

– ALOS

• Principal diagnosis ( Pdx)- is defined as the condition established after study to be chiefly responsible for admission of the patient to the hospital. It is important that the principal diagnosis be designated correctly because it is significant in cost comparisons, care analysis, and utilization review. It is crucial for reimbursement because many third-party payers (including Medicare) base reimbursement primarily on principal diagnosis

• Other reportable diagnoses (Secondary diagnoses)- conditions that coexist at the time of admission, develop subsequently, or affect patient care during the hospital stay. For UHDDS reporting purposes, the definition of "other diagnoses" includes only those conditions that affect the episode of hospital care in terms of any of the following:

– Clinical evaluation; Therapeutic treatment; Further evaluation by diagnostic studies, procedures, or consultation; Extended length of hospital stay; Increased nursing care and/or other monitoring


Medicare Case Finding: MS-DRG Impact Example

Case Overview

Summary: 55 year old female with left lower lung mass admitted for left lower lobectomy and

mediastinal / hilar lymph node dissection

PMH: COPD

Query

Opportunity

Clinical

Indicators

Impact

Abnormal diagnostic finding/ atelectasis

s/p LLL lobectomy with mediastinal LND 12/5, 12/7 febrile, CXR 12/6 showing minimal

atelectasis; CXR 12/7 minimal ground glass opacity left lung base maybe seen as

atelectasis; CXR 12/8 Subcutaneous emphysema along L lateral chest wall. Tiny pleural

effusions. 02 sat decreased to 91% RA Orders: 02, nebs, IV Cefazolin, serial CXR, pulm.

toilet

Original DRG: 165

Major Chest Procedure

W/O CC/MCC

New DRG: 164

Major Chest Procedure W/

CC

Impact

GMLOS 3.0 5.1 + 2.1

RW 1.7898 2.5170 + 0.7919

$ $12,157.67 $17,240.31 + $5082.64

SOI/ROM 1/1 1/1


Along Came APR DRG’s

• While many state Medicaid agencies continue to pay for inpatient

hospitalizations by the tried-and-true Medicare-severity diagnosis-related group

(MS-DRG) system, more are turning to the all patient refined (APR)-DRG system

• All Patients Refined Diagnosis Related Groups (APR DRG)- is a proprietary,

severity adjusted classification system used in reimbursement, quality and

reporting systems based on 4 subclasses of ROM and 4 subclasses of SOI.

• Severity of illness and ROM subclasses each categorized separately:

1-(minor)

2-moderate)

3-(major)

4-(extreme)


Acronyms Associated with APR-DRG ( continued)

• SOI- Severity of Illness The extent of organ system derangement or

physiologic decomposition for a patient. It gives a medical classification into

Minor, Moderate, Major and Extreme. The SOI class is meant to provide a

basis for evaluating hospital resource use or establish patient care guidelines.

Patients with higher SOI are more likely to consume greater healthcare

resources and stay longer in the hospital than patients with lower SOI in the

same DRG

• ROM- Risk of Mortality- a medical classification to estimate the likelihood of

in-hospital death for patients. The ROM Classes are Minor, Moderate, Major

and Extreme. Patients with higher ROM are more likely to consume greater

healthcare resources and have a higher likelihood of death in the hospital than

patients with lower ROM in the same DRG


Example-APR-DRG & Severity Adjustment


APR DRG Impact

• Medicaid in 24 states is using APR‐DRGs for payment

• 2 additional states have announced that they will

transition to APR‐DRGs in 2016/2017 for Medicaid

reimbursement

• – Alabama (October 2016)

• – Wisconsin (January 2017)

• 11 commercial payers and non‐Medicaid agencies are

using APR‐DRGs for payment

• Organizations in 30 states use APR‐DRG methodology

for payment and/or quality reporting


APR DRG Impact

Several agencies, consulting companies, data companies, etc. that report

quality data use APR‐DRGs to calculate expected rates and report on quality of

care

APR‐DRGs and quality

• Deaths

• Complications

• Length of stay

• Readmissions

• U.S. News and World Report

• AHRQ

• Healthgrades.com

• Premier, Inc.

• JCAHO


ICD-10 and Provider Documentation

• ICD‐10‐CM‐related DRG changes are a result of coding directives and not

change in code specificity

• Most ICD-10 PCS‐related DRG changes are the result of miscoding of

procedures and not physician documentation

• Almost all (90%) DRG changes deal with same issues as in ICD‐9

– is it acute, chronic, acute on chronic?

– Is there a link or cause and effect relationship between conditions

documented

– What is the etiology?

– Was it present on admission?

– Is it currently being treated or resolved?


Coding Tips Post ICD-10

• Coders and CDS can offer educational documentation tips based on industry

changes and updates

• Sequencing of COPD with acute

lower respiratory tract

infection and aspiration

pneumonia

• SIRS due to infection does not

code to sepsis without

clarification

• Toxic nephropathy no longer

shares the same code as acute

tubular necrosis

• Acute myocardial infarction is

assigned for first 4 weeks

following the diagnosis

Internal Medicine

• Paracentesis (therapeutic vs.

diagnostic)

• Debridements

– Skin

– Subcutaneous/fascia

• Degree and segments of

bowel resection

• Hepatic encephalopathy has

been re‐assigned to hepatic

failure with and without

coma

General Surgery


Current Initiatives-Pay for Performance (P4P)

• Pay for Performance

– Value Based Purchasing

• HACRP

• HRRP

• PSIs

• IQIs

• HACs


CMS P4P

• Total overall P4P outcomes can impact up to 6.0% of hospital Medicare

payments

• These outcomes are derived from coded data

SCORES ARE GREATLY AFFECTED BY

DOCUMENTATION AND CODING


Medicare Case Finding: MS-DRG Impact Example

Case Overview

Pt brought in for a bronchoscopy and VATS due to a lung nodule. PMH of anginal pain, BPH, CAD,

epididymis cyst, GERD, hypercholesteremia, OSA, pulmonary nodules, rectal cancer, shingles,

umbilical hernia. Stable post op course, wedge section positive for adenocarcinoma. Chest tube

removed with small right pneumo on 12/18 none on 12/20.

Query

Opportunity

Clinical

Indicators

Impact

Was this an expected outcome, inherent to procedure, or a complication, etc.

If considered a post‐procedural pneumothorax, J95.811, PSI 6/PSI 90 may apply.

(*code can be excluded: iatrogenic pneumothorax‐manually excluded cases with

any code indicating thoracic surgery, lung or pleural biopsy, or cardiac surgery).

Pneumothorax in the notes on 12/18.

Original DRG: 168

RES SYS OR PROC W/O

CC/MCC

New DRG: 167

RES SYS OR PROC W/ CCImpact

GMLOS 2.9 5.0 + 2.1

RW 1.3291 1.9818 + 0.6527

$ $6,771.76 $10,097.27 + $3,325.51

SOI/ROM 1/1 2/1


Value-Based Fee Adjustments for Providers

Hospital-IP Physician–IP or OPPhysician

(procedures)

E & M level of service Procedure

CPT CPT

MS-DRG History

Physical

Medical necessity Medical decision-making Medical necessity

Risk/Quality Risk/Quality Risk/Quality

Diagnoses/Procedures

ICD10CM/PCS

Diagnoses

ICD10CM

Diagnoses

ICD10CM

Patient Centered Around Episodes of Care


• Currently there are multiple quality and value reporting programs for Medicare

clinicians:

Physician Quality

Reporting Program

(PQRS)

Medicare Electronic

Health Records (EHR)

Incentive Program

Value-Based Payment

Modifier (VM)

NEW!

The Medicare Access & Chip Reauthorization Act of 2015 (MACRA)

Prior to MACRA- Fee-for-service (FFS) payment system, where clinicians are

paid based on volume of services, not value.

Change in Clinician Payment


Quality Payment Program-MACRA Ruling

• Repeals the Sustainable Growth Rate (SGR) Formula

• Replaces the SGR with a more predictable payment method that

incentivizes value

• Streamlines multiple quality reporting programs into the new Merit-based

Incentive Payment System (MIPS)

• Provides incentive payments for participation in Advanced Alternative

Payment Models (APMs)

The Merit-based Incentive

Payment System

(MIPS)

Advance Alternative

Payment Models

( APMs)

or


Merit-Based Incentive Payment System (MIPS)

• MIPS is a new program

– Streamlines 3 currently independent programs to work as one and to ease clinician burden.

– Adds a fourth component to promote ongoing improvement and innovation to clinical activities.

• MIPS provides clinicians the flexibility to choose the activities and measures that are most meaningful to their practice to demonstrate performance.

• Note : MIPS does not apply to hospitals or facilities

+Quality Resource Use Clinical Advancing care

practice improvement information

activities


Take Away Points

• The Quality Payment Program changes the way Medicare pays clinicians and offers financial incentives for providing high value care.

• Medicare Part B clinicians will participate in the MIPS, unless they are in their 1st year of Part B participation, become QPs through participation in Advanced APMs, or have a low volume of patients.

• Payment adjustments and bonuses will begin in 2019

• Claims-based

• Site information:

MACRA & MPIS:

https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/value-based-programs/macra-mips-and-apms/macra-mips-and-apms.html

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Quality-Payment-Program-MIPS-NPRM-Slides.pdf

https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/value-based-programs/macra-mips-and-apms/macra-mips-and-apms.html


The Future


Evolution of Healthcare


Summary

• The role of CDI can apply to multiple settings such as acute care, physician

practice, rehabilitation and long-term care and ambulatory/outpatient care

• Physicians must be taught the concepts of CDI in order to understand the

return on investment of the program and the benefits to them

• Physicians, Coders and CDI specialists need to unite around clinical

documentation

May the epic drama of adventure and exploration continue……………

42Proprietary and Confidential. Do not distribute.42

Thank You

Tara Engstrom RN CCDS | Optum360

Senior Consultant, CDI Consulting Services

[email protected]

mailto:[email protected]


Resources

http://healthcare-economist.com/2012/06/19/what-is-the-difference-between-drgs-ap-drgs-

and-apr-drgs/

http://journal.ahima.org/2016/08/03/cdi-gains-prominence-under-payment-reforms/

http://www.hcpro.com/HOM-242956-5728/Improve-your-CDI-program-with-severity-

adjusted-data.html

https://www.advisory.com/-/media/Advisory-com/Research/FLC/Resources/2015/CFO-

Brief-Future-of-CDI.pdf

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-

Based-Programs/MACRA-MIPS-and-APMs/Quality-Payment-Program-MIPS-NPRM-

Slides.pdf

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-

MLN/MLNProducts/Downloads/AcutePaymtSysfctsht.pdf

2016 ACDIS Conference-Physician Panel Session: Diagnosis and Assessment of ICD‐10;

G. Huff, MD, J. Fee, MD, J. Alexander Jr., MD, A. Martin DO

AHIMA-“Preventing Healthcare's Top Four Documentation Disasters”, Mary Butler

http://journal.ahima.org/2016/08/03/cdi-gains-prominence-under-payment-reforms/

http://www.hcpro.com/HOM-242956-5728/Improve-your-CDI-program-with-severity-adjusted-data.html

https://www.advisory.com/-/media/Advisory-com/Research/FLC/Resources/2015/CFO-Brief-Future-of-CDI.pdf


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