CDI Evolution 2017The Road to Risk Adjustment … · specificity driving quality scores, risk based...

CDIEvolution2017...TheRoadtoRiskAdjustment&QualityMeasurement

Presenter:PamHess,MA,RHIA,CDIP,CCS,CPCManagingDirector,CDI

TerryBuskeDirector,StrategicAccounts

June30,2017

2 ©2017himaginesolutionsinc.

“Eachhonestcalling,eachwalkoflifehasitsownelite,itsownaristocracybasedonexcellenceofperformance.”

JamesBryantConantPresidentofHarvardUniversityinthe1930’s


u WhatfactorsinthehealthcarelandscapearechangingtherequirementsofabestinclassCDIprogram

u HowtoredesignCDIprogramstoincludeallpatientcaresettings

u HowriskbasedpayermodelsaffectCDIprogramdesign

u Howtodevelopacollaborativeteamofinter-departmentalstakeholders

u HowtoutilizethelatesttechnologyanddataanalyticstoenhanceCDIprogramROIandfacilityrevenues

LearningObjectives


StakeholdersforTheCDIContinuumofCare

Coding Quality,UR,Compliance IT MedicalStaff

Leaders

RevenueIntegrity/Denials

ICD-10-CMspecificity

drivingqualityscores,risk

basedscoring,denialreduction

Improvequalityscoresandaccurate

payment throughcompleteandtimelyclinicaldocumentation

DataDrivenTechnologySolutions&

interoperabilityspanningallsites

ofservice

Essentialtoprogramsuccess,

physicianchampionsdrivetheprogramwiththemedicalstaff

Clinicaldocumentationdrivenchargecaptureroot

causeanalysis&decreaseddenials

CDIPre-encounter,ConcurrentandPost-encounterCaseReview


NewAdditionOutpatient&ProfeeCDIu EmergingCDIopportunitiesbeyondreviewingforMS-DRGbasedmajorcomplications

andcomorbidities(MCCs)andcomplicationsandcomorbidities(CCs).

u CDIprogramsareexpandingthescopeofworktoincludesupportofriskbasedpayermethodologiesandqualityreportingmetrics.

u CDSskillssetsareexpandingtoincludenotonlyclinical,coding,andcommunicationskills,butalsotheabilitytomanageworkflowredesign,quality,compliance,andregulatoryinitiatives.

u CDIprogramsaremovingoutsidethewallsofthetraditionalinpatientacute-caresettingintoothersettings,suchashospitaloutpatient,physicianoffices,long-termcare,andhomehealth.

http://www.icd10monitor.com/enews/item/1593-cdi-beyond-acute-care-and-reimbursement

Writtenby:MelanieEndicott,MBA/HCM,RHIA,CDIP,CCS,CCS-P,FAHIMASeniorDirectorofHIMPracticeExcellence,AHIMA


SellingtheConcept

GaininginterestinAmbulatoryCDIu Identifykeystakeholderandmedicalstaffleadersu MeettodiscusstheneedforambulatoryCDIu Presentauditresults(HCC,qualitymeasures,coding,medicalnecessitygaps)u ProposepilotsitetovalidateROIu Discussbestwaytocommunicatetheprogramtothemedicalstaff


ExampleROICalculation:HCCsu IdentifyRAFScores(beforeandafteraudit)OR

u IdentifyweightsforaddedHCCs

u IdentifyMedicareadvantagePerPatientPerMonthcontractrate

u ExampleCalculation:Addweightstogether(1.223),multiplyXPPPMrateX12u AnnualHCCpaymentincreasetotheMedicareAdvantagePlan=1.217X$897.90X12=$13,178.Next

Step– reviewpayercontractsCitation:https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Ratebooks-and-Supporting-Data-Items/2017Rates.html

HCC WeightDiabeteswithcomplications 0.318

Vasculardisease 0.4

CHF 0.323

Diseaseinteraction(DM+CHF) 0.182

Total 1.223


IdentifytheBestPilotSitesu Selectpilotsite(s)

● Formal/informalphysicianleaders● Primarycarepractices● SiteswithMIPSandqualitymeasuregaps

u Identifytargetsforfocusedcasereview●MIPSandqualitymeasuregaps● HCCcodingforMedicareAdvantage● Examplechargecaptureissue:Echocardiogramschargecaptureandcodingprocess

● Denials(NCD/LCD)o Observationvs.inpatientdocumentationo MyocardialPerfusiono Hyperbaricoxygentherapy


AmbulatoryCDIProgramComponents

u OutpatientFacility&ProfessionalPractice● Dataanalyticsforfocusareas● DetermineFocusAreas:HCCcapture,qualitymetrics,chargecapture,codingspecificity

● Conductcasereview● Redesignworkflow(pre,concurrentandpostencountercasereview)

● Educateprovidersandcoders● TrackandTrend

u Repeattheprocess!

Overarching orindependent basedongovernancemodel:


RedesignWorkflowTaskListu EstablishandobtainagreementonCDSintegrationprocess(clinicmanagerand

physicians)● Patientidentificationfocusedcases(HCC,denials,MIPS)● Casereviewlocation:Remotevs.on-site● Casereviewtype:

o Pre-encounter(inpatient,outpatient,professionalfee)o Concurrento Post-encounter

● Querycommunication:alert,tasks,notes,in-linecommunicationtechnology● Createprocessfortimelycasebilldrop

u EstablishCDScasetrackingmechanismu Establishmonitoringandtrendreporting


ExampleOutpatientCDIFocusArea

CDI/CodingcasereviewsareacriticalcomponentofaneffectiveOutpatientClinicalDocumentationProgram.

OPPSFinalRule11/1/16presents25newComprehensiveAPCsfor2017(alsocalledC-APC):

u 1,877CPTcodesarenowgroupedintothenewC-APCsincreasingthenumberfrom66to312

u WhenaprimaryprocedureassociatedwithaC-APCisreportedwithasecondC-APCprocedureorpackagedaddoncodetheCMSpaymentwillbeequaltothenexthigherAPCinthegroup.

Citation:https://acdis.org/articles/news-outpatient-payment-system-final-rule-includes-measures-watch


ExampleOutpatientCDIFocusAreaCMSOutpatientQualityOP-8MRILumbarSpineforLowBackPain

u Lownumeratorsarethegoalu Removecaseswithmodifier-26u Removecaseswithcodeddiagnosis

orhistory:lumbarspinesurgery,infectiouscondition,treatmentfieldsforradiationtherapy,trauma,unspecifiedimmunedeficiencies,cancer,etc.)

Citationhttp://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier2&cid=1228695266120


OIGRiskAdjustmentDataValidationAudit

u OIGmonitorsHCCdocumentation

u Mostfrequentdocumentationerrortype:

● A.Unsupporteddiagnosiscoding

Citation:DepartmentofHealthandHumanServices,OfficeofInspectorGeneralReportSeptember2012,ParamountCare,Inc.

CodedDataandAnalyticsToolsPhysicianPracticeCDI


EHRDocumentationforMIPSandAdvancedAPMs

EHRConsiderations:u EHRsystemsmayallowfordatacapturethatisnotsupportedbydocumentation

u LargeamountsofrevenuearetiedtoreportingundertheQPPprograms,andlackofsufficientdocumentationcouldresultindenialsandpenalties

u Developmethodtoavoidinterruptingproviderworkflowstoenterqualitydata

u Highsuccessrateshavebeenachievedwithdocumentationanddatacapturebyusingin-linemeasuredocumentationinEHRtemplates● In-linedocumentationreferstotheprocessofallowingtheprovidertodocumentmeasurerelatedinformationwithinthebodyofaprogressnotetemplate.

● Improvesefficiency,providereffectiveness,measuredatadocumentationandmeasureperformance

Citations:http://journal.ahima.org/2016/06/02/macra-mips-and-advanced-apms-time-to-prepare/Marron-Stearns,Michael."HowMACRAChangesHIM"JournalofAHIMA88,no.3(March2017):22-25.


In-lineDocumentationforQuality(MIPS)Measures

Example:DiabeticPatientu Theproviderispromptedtodocumentinformationaboutthepatient’smostrecentdiabeticeye

examination.

u Theproviderisgivenaseriesofmenuchoicesthatwillbemappedtotherequirementsforthismeasure.

u Theprovidermayalsobepromptedto:● Generateanophthalmologyreferral● Documentthatthepatienthasdeclinedthedilatedeyeexamination,becausethemostrecentexaminationtookplacewithinthespecifiedtimeframeandwasnormal

● Otherfindingsthatmeetthemeasurerequirement,includingexclusions.

Citations:http://journal.ahima.org/2016/06/02/macra-mips-and-advanced-apms-time-to-prepare/Marron-Stearns,Michael."HowMACRAChangesHIM"JournalofAHIMA88,no.3(March2017):22-25.


HCCAnalytics

MedeAnalyticsde

ExampleReport:Perprovideranalysis• Totalclaims• RAFscore(3yeartrend)• TopImpactHCC,• E&MDistribution


RevenueRisks– MissingCharges

MedeAnalyticsde

ExampleReport:showspotentialchargecapturegapsrequiringfurthervalidationbyoutpatientCDS


RevenueRisks– ProcedureRelated

MedeAnalyticsde

ExampleReport:showspotentialprocedurecodegapsrequiringfurthervalidationbyoutpatientCDS


ComplianceRisks

MedeAnalyticsde

ExampleReport:showspotentialCPTcodeandglobal

packagecompliancegapsrequiring

furthervalidationbyoutpatientCDS


SteamlinedQueryProcess

providentedge.com

PersonalMobileDevice:Providerresponseandclinicalrecordupdateinoneclick

UpcomingEvents:AlamoAreaHIMAinAugustHAHIMAinSeptAHIMAAnnualMeetinginLA- OctACHE2017HealthcareLeadershipConferenceinHouston– Oct

Questions&Answers

Thankyoufriends!


u Pamela C. Hess is the Managing Director, CDI at himagine SolutionsInc. She is a nationally recognized expert in Health InformationManagement with extensive healthcare experience in revenuecycle operations, clinical documentation improvement, electronichealth record applications, reimbursement, coding, billing,compliance, quality control, and coding training. She is known inthe industry as a trusted advisor and subject matter expert, and hasauthored the original edition of the Hospital Charge DescriptionMaster Guide, by OptumCoding, Cardiology Procedural CodingSelect, by Decision Health and most recently ClinicalDocumentation Improvement- Principles and Practice by AHIMAPress. Her experience in the healthcare industry has focused on CDIprogram implementation at large academic medical centers andmedium to small regional facilities. She has extensive experiencemanaging HIM operations as a consultant and as a health systemHIM director. Prior to joining himagine, she led the CDI service linefor Deloitte & Touche, LLC and Navigant Consulting, Inc. She iscurrently the President of the Arizona Health InformationManagement Association.

PamelaHess– ManagingDirector,CDI

[email protected]:813-331-0711


u 25 years’ experience in driving economic improvements inhealthcare. He began his career in billing & insurance resolution.Towards the end of the Clinton administration, he was appointed bythe Deputy Director of the Veteran Health Administration to serveon a National Revenue Taskforce; subsequently consulting withDepartment of Defense Hospitals, DHHS and the Indian HealthServices. From there, he progressed to continuous processimprovement and helped drive expansion of the 1115 MedicaidWaiver in Texas and California. Prior to joining himagine, Terry wasthe Sr. Vice President for a private equity group helping incubatehealthcare start-ups. He has been involved with the AmericanCollege of Healthcare Executives since 2009 and has beenmentored by some of the best CEO’s in the Texas Medical Center. Asa member of the Healthcare Financial Managers Association andAHIMA; he is passionate about contributing to TxHIMA andsupporting regional HIM chapters across Texas.

TerryBuske– Director,StrategicBusinessDevelopment

[email protected]:(813)331-0734Mobile:(218)703-6133

CDI Evolution 2017The Road to Risk Adjustment … · specificity driving quality scores, risk based...

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