ICD-10 - Optum · ICD-10 physician education — Engaging your physicians for a smooth transition...
Transcript of ICD-10 - Optum · ICD-10 physician education — Engaging your physicians for a smooth transition...
Coding services: Your ace in the hole for ICD-10
Presented by: Terry Santana-Johnson, Coding Services Product Manager, Optum
In this session, you will gain a deeper understanding of concerns about keeping up coding productivity through the transition to ICD-10. You will learn how to:
• Figure out how much coverage you may need in coding services
• Choose a worthy partner for your coding needs and how technology can help
• Evaluate the quality of services you are receiving
ICD-10 education — Strategic considerations for how to educate your organization
Presented by: Deena Kerr, ICD-10 Education Director, Optum
In this session, we share guidelines and best-practice considerations that will help your organization execute a solid approach to ICD-10 education. We offer insight on how to better leverage the corresponding activities that can accompany and enhance the education process, and we’ll discuss:
• Areas of impact: Which groups to focus on, and how to address their varying educational needs
• Timing considerations: When to start educating people in their various roles
• Process: How to develop and implement a training program that meets your organization’s specific educational needs
Radical thinking… “Let’s let doctors be doctors!”
Presented by: Cecilia Guardiola, JD, RN, Associate Director, CDI Consulting, Optum
Lynn Probert, Optum CDI Product Specialist, CDI Subject Matter Expert, Optum
In the current environment of ever-changing documentation requirements from CMS, reductions in payments for services rendered and increased public reporting of performance statistics, it is imperative that the medical record completely capture an accurate reflection of the patient and treatments rendered.
In this session, you will learn how the Optum CAC/CDI Single solution will facilitate the efficient screening of cases for those conditions that are undocumented or need to be specified more clearly in the medical record. You will also learn how the NLP and LifeCode bring the cases to the users, allowing for specific case finding in the first-of-its-kind method in the CDI environment.
ICD-10 physician education — Engaging your physicians for a smooth transition
Presented by: Deena Kerr, ICD-10 Education Director, Optum
One aspect of your ICD-10 transition plan that must not be overlooked is physician training and education. Provider documentation is as important as coding when it comes to successful ICD-10 implementation. Hospitals need to develop a strategy now to ensure that physicians are ready, willing and able when ICD-10 coding becomes a reality in 2014. Learn more about strategies and approaches to consider when constructing your own physician ICD-10 transition plan.
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ICD-10Big changes bring big opportunities.Comprehensive ICD-10 solutions to help you strengthen organizational performance
BOOTH#1238BOOTH#1238
Thank you for joining Optum™ at this year’s AHIMA Convention and Exhibit. As the ICD-10 transition approaches, we invite you to download our presentations from the show to learn how we can support you in taking on new challenges and making the most of new opportunities.
ICD-10 preparedness: Countdown is on … are you on track?
Presented by: Emily Rafferty, Vice President, ICD-10 Provider Consulting, Optum
Is your organization applying best practices to transition to ICD-10? In this session, an ICD-10 industry thought leader will explore various ICD-10 strategies, including vendor/ payer readiness and contingency planning, communication and awareness campaigns, revenue mitigation strategies, mapping and translation methodologies, and coder productivity mitigation strategies. At the end of this session, you will have an understanding of the key strategies leading organizations are implementing to mitigate their risk with the transition to ICD-10.
Concurrent CAC with computerized CDI at UPMC: Lessons learned from implementation
Presented by: Julie Truver, MSIS, RHIA, Vice President of Operations, UPMC Technology Development Center
Adele Towers, MD, MPH, Medical Director, UPMC Health Information Management
This presentation focuses on the challenge that the University of Pittsburgh Medical Center (UPMC) faced with their CDI program and how they are evolving their program (as we speak) into a more automated initiative, utilizing natural language processing at its core. Presenters will discuss their data outcomes from the concurrent CDI.
Objectives: After this session, you will be able to:
• Explain the CDI challenge at UPMC
• Identify how technology can improve the CDI process
• Describe how a natural language processing (NLP)-driven CDI can enhance staff productivity, coding accuracy and compliance
• Highlight lessons learned and opportunities discovered from CDI implementation
• Review the transition from post-discharge CAC to concurrent CAC
NLP innovation for CAC and CDI — An update on new technology
Presented by: Mark Morsch, Vice President of Technology, Optum
In this session, you will learn about recent advances in NLP technologies for CAC and CDI. The Optum LifeCode NLP engine includes new patent-pending capabilities to identify detailed clinical information within medical records. This new technology will transform CDI programs by automatically marking cases with documentation deficiencies. For ICD-10, new capabilities in compositional
NLP will be key to recognizing the greater specificity of the new coding system. You will also learn how compositional NLP combines elements from across the medical record to follow complex coding guidelines.
The benefits of automating compliance management
Presented by: Lee D. Valenta, Executive Vice President, Optum
Providers, health plans and payers are subject to a regulatory environment today that is becoming more and more complex. With audits expanding and serious financial penalties being enacted, health care companies need a better way to handle compliance requirements. Optum Compliance Suite is a flexible, cloud-based solution that offers an integrated, unified approach. Find out how guided workflow with automated tools reduces the time, effort and resources involved in multiple compliance processes and audit preparation. Understand how you can be in a continuous state of audit readiness while actually lowering your costs for compliance management.
How to improve physician relationships using CAC and concurrent coding — A case study from Mission Health
Presented by: Susan Hoyle, CCS, Mission Health System
Mission Health chose to implement a computer-assisted coding solution to increase coding productivity and accuracy, in preparation for ICD-10. But they soon determined that their new CAC system could also enable concurrent coding and strengthen not only their coding accuracy but also their physician relationships. Mission Health’s coding and revenue cycle leaders decided to move from a post-discharge coding process to a concurrent coding process. Learn how Mission Health worked with its computer-assisted coding system to enable its concurrent coding process, and how the results helped the hospital system and the system’s affiliated physicians.
ICD-10-CM mapping: Reasons, rules and restrictions
Presented by: Anita C. Hart, RHIA, CCS, CCS-P, Product Manager for ICD-9-CM and ICD-10-CM/PCS, Optum
Mapping is a very useful tool when undergoing the change to ICD-10-CM/ PCS. It can be especially beneficial when transitioning coding practices, converting reports, and validating software and clinical documentation practices. Download the presentation to learn how to wisely use mapping in combination with other resources in order to effectively transition from ICD-9-CM to ICD-10-CM/PCS by identifying and resolving issues, setting decision-making rules and planning for change. You’ll walk away knowing the benefits of mapping and rules to follow, as well as understanding what mapping was not designed to do.
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Coding Services: Your Ace in the Hole for ICD-10
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Forging ahead to ICD-10 Hospitals continue preparation
• Evaluation of current electronic medical records
• Evaluation of current coding software
• Reducing redundancy of systems
• Continuing physician education toward ICD-10 documentation
• Review of current coding functions
– Review of current processes
– Workflow re-engineering
• Evaluate educational requirements
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Evaluate and revise coding workflow
Evaluation of current coding software
• Grouper evaluation – Products – Features
• New technology – CAC
Review of current coding functions
• Review of current processes
• Workflow re-engineering
Education of staff
• Baseline
• Who, what, where?
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The coder shortage Impacts to coding professionals
• CDI
• EMR data extraction
• Regulatory environment – Core measures – POA – RAC – ICD-10
• Shortages – Lack of experienced, credentialed coders – Lack of qualified coding management – Retirement!
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Medical records professionals aging population
Source: http://cew.georgetown.edu/healthcare, Georgetown University Center on Education and the Workforce; Healthcare, 2012, Carnevale, Smith, Gulish, Beach; accessed 7/19/2012
0
5
10
15
20
25
30
18-24 25-34 35-44 45-54 55-64 65-74
Age Distribution of Medical Records & Health Information Technicians (includes Coders)
% Population
48% of HIM professionals
are greater than 45 years of age
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Considering purchased services
Company Size • Tenure in health care
Experienced • How many years are required?
Credentialed • AHIMA, AAPC, clinical credentials
Committed to medical coding • Recognized in the coding space
Ability to provide remote services • Secure connectivity
Technology company • Workflow, CAC
Global resourcing pricing advantages
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Considerations What is the end goal?
• Reduce DNFB
• Fill for vacancy
• Fill for medical leave
• Fill for vacations
• Transition current staff to new roles
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Issues addressed
Quality issues with current staff
• Maintaining an audit program
• Education and re-education
Unable to find qualified coders
• Serious competition for resources
Want technology but funds are limited
• CAC is what it’s all about!
• Other code assist technologies??
Lack of coding management resources
• Shortage of prepared management/ coding abilities
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Temp coders
Onshore and offshore
Onsite services
Remote-only services
Coding service options:
ON DEMAND
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Service line or department outsourcing
Onsite services
Remote-only services
Coding service options:
STEADY STATE
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Complete HIM coding department outsourcing
Company takes on management of coding-related functions
Coding service options:
FULL OUTSOURCING
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Pricing considerations
Costs
• By coder
• By hour
• By chart – Chart type
How much support will you need?
• Estimating productivity losses
• Vacation leave
• Anticipated medical/ maternity leave
• Vacancy backfill
Thank you.
Terry Johnson, RHIT, CDIP, CCS, CCS-P — Solutions Architect 434-963-2519 [email protected]
Can managing compliance be automated?
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What we’ll review today
Compliance and risk management
Cost of compliance
Successful automation
Compliance automation: ROI
Proactive compliance management
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Compliance affects all levels of the organization
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How do we interpret and manage compliance across an enterprise?
Complex, manual and spreadsheet-based workflows, changing regulatory standards delay response and increase cost
Monitoring compliance-related business process s involved in day-to-day work is incredibly time consuming
Ensuring the organization complies with regulations and standards so that we can focus on business without incurring high costs of non-compliance
Compliance visibility across the organization and changing regulations are senior executive challenges
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Compliance management: Processes of many tasks
Compliance assessment and corrective-action plan
Continuous monitoring of compliance elements in business process
Incidents and complaints management
Third-party vendor compliance management
Mock audits and reports
Staff awareness and training
Identify compliance requirements
Identify business process elements to monitor
Develop methods to collect and report incidents and complaints
Identify specific areas and frequency of due diligence
Identify key audit areas for mock audits
Identify training needs
Develop assessment methodology
Develop rules for process monitoring
Review, assess risks associated with incidents and prioritize
Set up and schedule due diligence
Prepare audit protocols
Provide new employee and refresher training courses
Conduct assessment Collect data and compare with rules
Investigate and provide resolutions
Collect and review compliance data from third parties
Collect information, sample data and documents
Customize training for organization roles
Report findings and recommendations
Identify gaps, risks and alerts Manage resolutions
Report to management and provide CAP suggestions
Review and provide findings report
Test and confirm the understanding
Develop and implement CAP
Provide feedback to mitigate risks
Report incidents and compliance risks and resolution
Contractual decisions based on diligence report
Fine-tune audit response and be prepared
Document training provided for audit requirements
Continuous oversight: policies, procedures, controls
Continuous oversight on gaps and risks
Continuous oversight on incidents and complaints
Continuous over- sight on third-party compliance adherence
Continuous review of audit findings and risks
Generate reports for management, external auditors
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Provider Focused Condition Tracking /
HIPAA
PHI / Research
Data Integrity & Filtering
Abstraction & Tracking
Compliance & Reporting
Stark Law
Conflict of Interest Reporting
Clinical Decision Support Malpractice Medication Management
Health Data Access & Interoperability Outcomes Measurement
CMS Compliance Audits / RAC Reviews Performance-based Reimbursement/P4P
Clinical Coding Integrity
Meaningful Use /
Patient Privacy
Contract
Adherence Legal & Other
Joint Commission Accreditation
Clinician Education / Certification
Charity Care Reporting
Referrals / Pr-e Authorizations
Eligibility Verification
Demo - graphics /
Clinical
Compliance
Financial Administration
Compliance
Stimulus Qualification
Clinical Auditing
Population Health
Management
Analytics / Reporting
Education
Medication Adherence
PHM Program Delivery
Incentive Management Participant Engagement / Outreach
Fraud
Claims Editing Payment Integrity
Data
Population Stratification & Patient Identification
Overpayment Detection
Auditing / Investigations Subrogation
ICD -10
Data
Overpayment
Member
Chart Extraction
Clinical Coding
Co -morbid Condition
Identification
Management Reporting
Payer Focused
Preparedness Mining & Analytics
Recovery / Collection
Targeting
Health care compliance requirements: Increasingly complex!
Triple Tree report on health care compliance, 2010
Regulatory compliance
Payment integrity
Clinical compliance
Meaningful-use stimulus
qualifications
Revenue cycle management
HIPAA Privacy and
Security
Medical necessity
The Joint
Commission
Clinical quality measures
Clinical safety
RAC audits
Coding compliance
FWA
ICD-10
Payer Contracts
Medications
Decision support Medications
STARK
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What we’ll review today
Compliance and risk management
Cost of compliance
Successful automation
Compliance automation: ROI
Proactive compliance management
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Non-compliance is not an option Studies show that non-compliance is less costly than compliance
Source: Ponemon Institute Cost of Compliance Report 2011
Compliance cost
Policy
Communications
Program management
Data security
Compliance monitoring
Enforcement
Non-compliance cost
$9,368,351 $3,529,579 AV E R AG E C O S T
Activity-based costing model
Indirect costs
Opportunity costs
Direct costs
Business disruptions
Productivity loss
Revenue loss
Fines and penalties
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What we’ll review today
Compliance and risk management
Cost of compliance
Successful automation
Compliance automation: ROI
Proactive compliance management
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Successful compliance management automation
Dashboards and decision-making tools
Content and workflow tools
Optimizing the compliance capabilities
Reduced cost of compliance
Automation Reduce cost and risk
Translating complex regulations into simple business processes
Compliance management-guided workflow to increase efficiency
Automate day-to-day compliance manage-ment process and tasks
Identify incidents, events and processes that affect compliance as they happen
Be proactive
Early identification of risks to mitigate them
Timely regulator response to reduce penalties
What is our compliance posture?
What are the vulnerabilities?
How are we managing risks?
Awareness Understanding Managing ROI
Visibility Simplification
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Visibility: Identify, understand the risks
Dashboard to display risks, compliance posture and incidents that need attention
Compliance management activities data
Compliance-related incident data
Regulations database
Policies and procedures
Compliance posture and risks are identified using
an analytical engine
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Simplification and automation
Monitor compliance • Investigate and manage incidents • Monitor vendor compliance • Identify compliance events that could become non-compliance issues
Compliance status, alerts, decisions
and risk protection
Audit and preparedness
Internal Audits
External Audits
Workflow for compliance management • Identify gaps and take corrective actions • Manage policies and procedures • Identify vulnerabilities and risks
Compliance requirements summation Translating regulations to easy-to-use content and workflow tool
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Compliance and risk management
Cost of compliance
Successful automation
Compliance automation: ROI
Proactive compliance management
What we’ll review today
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Return on investment
• Automated process to reduce time, resources involved • Increased collaboration with intelligence-based system, less duplication
Significantly reduce time and effort of managing compliance
Cost of non-compliance • Business disruption: loss of revenue • Financial penalties: now in millions of dollars • Legal and other related costs with high business impact
Reduce risks of regulatory penalties
Suspension from doing business; publicized compliance events may result in loss of customers
Prevent reputational damage
Automation is highly cost-effective, optimizes compliance productivity
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Compliance and risk management
Cost of compliance
Successful automation
Compliance automation: ROI
Proactive compliance management
What we’ll review today
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Be proactive in managing compliance
Compliance Automation
Regulatory compliance
Payment integrity
Clinical compliance
Meaningful-use stimulus
qualifications
Revenue cycle management
How can we more effectively monitor compliance incidents?
What are the financial, operational and administrative compliance requirements for our organization?
Can we reduce the cost of compliance? How can we be
prepared for an audit?
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Questions Answers
ICD-10 Preparedness: Countdown is on…are you on track?
Communication and awareness
Education and training
Revenue mitigation
Coder productivity/retention
Report remediation
What we’ll review today
Q1 2013 Q2 2013 Q3 2013 Q4 2013 Q1 2014 Q2 2014 Q3 2014 Q4 2014
Report remediation
Education
Revenue mitigation
Coder productivity/retention
Communication and awareness
Report/Form Identification
Crosswalk Strategy
Report/Form Remediation
Convince Clarify Involve
System Identification
System Remediation
360° Testing
KPI Benchmarking
Denials Management/ Payer Contingency
Contract Review
CDI Program Review
CAC Implemented
Coder Backfill and Retention Strategy
Compliance Date: Oct. 1, 2014
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Vendor selected
Coder CDI/physician champion
All learners Practice coding
System remediation
Inform
Start of process Decision point
Section I
Communication and awareness
Education and training
Revenue mitigation
Coder productivity/retention
Report remediation
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ICD-10 communication stages
Broad awareness campaigns
(to the masses)
Department meetings: change management
Role-specific training
Workflow optimization
Inform Clarify Convince Involve
“How will ICD-10 affect my job, roles and responsibility?”
“How do I use ICD-10 in my job?”
“When are we moving to ICD-11?”
“What is ICD-10 and how do I get more information on how we are addressing it as an organization?”
Awareness Understanding Acceptance Commitment
6
ICD-10 communication and awareness
Don’t be afraid to have some fun.
Get creative!
Section II
Communication and awareness
Education and training
Revenue mitigation
Coder productivity/retention
Report remediation
8
Methodology to approach physicians
• Includes both employed/non-employed providers • Focus is on acute-care clinical documentation requirements
All affiliated providers
• Includes employed providers within medical group • Focus is on documentation and coding requirements in the physician
practice (professional) setting
Employed providers only
• Includes all non-employed community providers affiliated with the hospital • Focus is on awareness/education of both impacts and potential remediation
activities
Community providers
Communication and awareness
Education and training
Revenue mitigation
Coder productivity/retention
Report remediation
Section III
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Revenue mitigation: Creating a baseline
Key Performance Indicators
Case Mix Index
(CMI)
Coding productivity and quality
Denials Discharged
not final billed (DNFB)
Reimbursement by service line
What metrics should we be
collecting?
Who will be accountable
for taking action?
How should we report the information?
When should we start benchmarking
our data?
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Contingency planning: Be prepared
• Will you be able to proactively identify the payers that will not be ready/compliant by Oct. 1, 2014?
• If so, do you want to take a proactive or reactive approach, i.e., let the claims deny or map/code to ICD-9 before submitting?
• Will you dual-code claims or map from I-10 to I-9?
• Which department will be responsible ― HIM or PFS?
• Do you have workflows within your application to support your strategy?
Communication and awareness
Education and training
Revenue mitigation
Coder productivity/retention
Report remediation
Section IV
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Coder productivity mitigation plan
• You can always hire more coders, right? • Transition to computer-assisted coding • Be creative ― consider a coder career
ladder program • Remote coding (retention vs. productivity
mitigation strategy?) • Considerations:
– While coders are in training (minimum 40 hours for IP coder, but likely more)
– Through dual-coding period – Post-transition (learning curve) – Retention
Anticipated coder productivity impact of ICD-10*
Long-term
Short-term
50% 25%
*http://library.ahima.org/xpedio/groups/public/documents/ahima/bok3_005558.hcsp?dDocname=bok3_005558
Communication and awareness
Education and training
Revenue mitigation
Coder productivity/retention
Report remediation
Section V
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Forms and report remediation
Remediate Develop
consistent mapping strategy
Prioritize Inventory
• Select an organization-wide mapping and translation tool
• Identify HIM analysts and support
• Compliance (regulatory, state, CMS, other)
• Quality
• Financial
• Frequency, prevalence
• Review with end user
• Survey
• Meet with business impact areas
• Determine vendor vs. internal
• Charge tickets
• Vendor reports
• Ad hoc/ custom reports
• Order sets
• Clinical templates
• Cheat sheets
Reports and
forms are everywhere!
Questions
Thank you.
NLP innovation for CAC and CDI — An update on new technology
Mark Morsch Vice President Technology
1 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
New technology for ICD-10-PCS Compositional approach to NLP Opportunity to leverage partial information Advantage of partial PCS coding
NLP advancements transforming CDI Case finding automation Clinical information model Linkage between CAC and CDI
CDI example
Q&A
AGENDA
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Compositionality
ICD-9 38.93 “Venous catheterization, NEC” maps to 185 ICD-10 PCS codes.
02HS03Z Insertion of infusion device into right pulmonary vein, open approach
02HS33Z Insertion of infusion device into right pulmonary vein, percutaneous approach
02HT03Z Insertion of infusion device into left pulmonary vein, open approach
05H003Z Insertion of infusion device into azygos vein, open approach
Basic concept Side Location Approach
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Compositionality Example: 0FB40ZZ partial gallbladder removal, open approach OPERATIVE REPORT PRINCIPAL DIAGNOSIS: Cholecystitis with cholelithiasis with history of emphysematous cholecystitis. PROCEDURE: Open cholecystectomy with intraperitoneal drain placement and removal of cholecystostomy tube. … PROCEDURE … We then did identify the gallbladder, and we were able to grab with a Kelly clamp and lift it up. It was very inflamed. The cholecystostomy tube did go through the liver and into the gallbladder as we had anticipated. … We then did a dome-down technique to take the gallbladder down. … Therefore, I felt the best thing to do was piecemeal remove the gallbladder and then keep the back wall intact where we could. Actually this area was quite small, so therefore we took out several pieces of the anterior wall of the gallbladder, and then we had a lip of posterior wall of the gallbladder that we could sew the gallbladder back closed just at the infundibulum. There was maybe 0.5 cm of gallbladder remaining. … Therefore, we closed the approximately 2 cm and 0.5 cm depth of gallbladder with Vicryl sutures. … We irrigated this several times, and there was no bile coming from the gallbladder remnant whatsoever. …
Procedure (removal) Removal (gallbladder) Removal (partial) Approach (open)
Partial removal — 0FB Gallbladder — 4 Open approach — 0 No device/qual — ZZ
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ICD-10-PCS code structure
PCS codes consist of seven alphanumeric slots, each slot assigned a specific meaning
Section 0
Slot 1 Section Medical & surgical, imaging …
Slot 2 System Gastrointestinal, lower bones …
Slot 3 Root procedure Bypass, alteration …
Slot 4 Body part Esophagus, stomach …
Slot 5 Approach Open, percutaneous …
Slot 6 Device Drainage, infusion …
Slot 7 Qualifier Syngeneic, zooplastic …
Fully specified PCS where information for all seven slots identifiable.
0W9F0ZZ Abdominal wall drainage, open approach
Partially specified PCS where confidence in information for some slots only.
0W9F_ZZ Abdominal wall drainage, approach not specified
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Leveraging partial information in PCS codes
A diagnostic bronchoalveolar lavage (33.24) was performed, but the physician did not adequately specify the location for ICD-10.
0: Medical & surgical
B: Respiratory system
9: Drainage
_: Body Part?
8: Opening, endoscopic
Z: No device
X: Diagnostic
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Partial CD-10-PCS code: Interaction with book coding
• All possible selections for each character are presented
• Drop-down list and segment selection allow coders to adjust PCS code
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Advantage of partial PCS coding
Supports clinical documentation improvement where specificity increases from ICD-9 to ICD-10
NLP suggested codes need not be all or nothing
Provides for PCS code auto-complete capability
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Natural language processing (NLP) is transforming HIM and coding with computer-assisted coding (CAC) solutions
• Benefits: Productivity, accuracy, efficiency, transparency, manageability
• CDI programs share these same goals
However CAC is not the same as CDI
Not limited to finding only “code-able” facts, but clinically significant facts that are evidence of an information gap
Transformation opportunity for CDI
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Factors aligning NLP with CDI
Accurate abstraction of medical evidence to automate case-finding
Clinical information model that supports
consistent query decisions
Compositional approaches to NLP
to recognize complex query scenarios
1 2 3
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NLP can extract the clinical evidence that indicate gaps in documentation
Like in CAC, recall and precision are important measures of accuracy
• High recall ensures that a high proportion of relevant facts are captured
• Capture important facts that can escape manual processes
• High precision means CDI specialists don’t waste time reviewing cases that don’t have gaps
Comparing CDI evidence to CAC results provides automated validation
Case finding automation with LifeCode® NLP
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Three-tier information model MARKER • Marker Source = CDI • Marker Label = Condition or Procedure • Marker Type = Type of Marker • Confidence = High, Medium, Low • SNOMED Concept ID = simple or complex
SNOMED representation
SCENARIO: Group of indicators specifying the reason for a Marker • Scenario label • Confidence • SNOMED Concept ID
INDICATOR • Indicator label • Indicator type • Finding or lab or vital or meds or supplies with full inherited output • SNOMED Concept ID
Marker
Scenario Scenario
Indicator Indicator Indicator
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CDI example — Congestive Heart Failure
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CDI Marker — Acute Systolic Heart Failure
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• NLP for CDI cannot be limited to narrative text — should have capability to handle structured data
• Structured and semi-structured data are an important source of clinical evidence – Vital signs – Laboratory order and results – Medication orders
• NLP for CDI should have high-accuracy coding capability to create effective ICD-10 queries
Key requirements of NLP for CDI
• NLP for CDI should have access to the complete record — or as much as possible
Clinical evidence + No ICD-10 code Physician query
Clinical evidence + ICD-10 code No query
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New NLP technology for ICD-10-PCS and CDI
Advantage of partial PCS coding • NLP results are not all-or-nothing • Integrates with references for quick completion
Transforming CDI • Case finding automation • Clinical information model
Compositional NLP is key to both CDI and ICD-10-PCS
Conclusions
Q&A
ICD-10-CM Mapping: Reasons, rules and restrictions
Anita C. Hart, RHIA, CCS, CCS-P OptumInsight Product Manager, ICD-9-CM and ICD-10-CM/PCS AHIMA-Approved ICD-10-CM/PCS Trainer
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Reasons The WHEN, WHERE and WHY to employ Mapping
Rules The BEST PRACTICES to follow when using Mapping
Restrictions The CAUTIONS and LIMITATIONS of Mapping
Readiness The PLAN assessment
AGENDA How to develop an applied mapping
Decision-making process for choosing translation alternatives applied for a specific purpose
Reasons
3 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
REASON 1
To establish focus of coding training
Key factors
Code set expansion
Body system code count differences
Coding guideline and instructional changes
Major classification axes changes in specific coding areas
4 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
REASON 1 — To establish focus of coding training
Examples:
Code set expansion
ICD-10-CM MAPPING: REASONS, RULES AND RESTRICTIONS
Body system code count differences
Chapter ICD-9-CM ICD-10-CM Infectious & Parasitic 1,270 1,049
Circulatory 474 1,239
Respiratory 254 324
Pregnancy 1,103 2,145
Injury & Poisoning 2,544 39,761
ICD-10-CM (2014 Draft) codes = 69,367 vs.
ICD-9-CM (Vol.1) FY 2014 codes = 14,568
5 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
REASON 1 — To establish focus of coding training
Example: Coding guideline and instructional changes
ICD-9-CM: Aftercare Codes Aftercare visit codes cover situations when the initial treatment of a disease or injury has been performed and the patient requires continued care during the healing or recovery phase, or for the long-term consequences of the disease. [ICD-9-CM CG Oct 1, 2011 Sect I.C.18.d.7]
ICD-10-CM MAPPING: REASONS, RULES AND RESTRICTIONS
ICD-10-CM: Subsequent Encounter vs. Aftercare Subsequent Encounter: • Extension “D” subsequent encounter is used for encounters
after the patient has received active treatment of the injury and is receiving routine care for the injury during the healing and recovery phase.
• Aftercare, Z codes should not be used for aftercare of injuries. [ICD-10-CM CG 2014 Draft Sect I.C.19.a]
Aftercare: • Aftercare visit codes cover situations when the initial treatment
of a disease has been performed and the patient requires continued care during the healing or recovery phase, or for the long-term consequences of the disease. [ICD-10-CM CG 20141 Draft Sect I.C.21.c.6]
6 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
REASON 1 — To establish focus of coding training ICD-10-CM MAPPING: REASONS, RULES AND RESTRICTIONS
Examples:
Major classification axes changes in specific coding areas • Method of detection for tuberculosis infection
• Legality status and completion of abortions
• Trimester vs. episode of care for pregnancy
• Hypertension
• Transient hypertension in pregnancy vs. gestational hypertension w/ and w/o proteinuria
• Underdosing of drugs and chemicals
7 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
REASON 1 — To establish focus of coding training ICD-10-CM MAPPING: REASONS, RULES AND RESTRICTIONS
• Identify facility-specific high-volume codes based on utilization/reimbursement
• Focus training based on code utilization and facility-specific coding issues
• Prepare real-time training coding in both code sets
• Compare coded results
• Test coding proficiency in specified code set
Key Action Items
8 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
REASON 2
To identify clinical documentation essentials
Key factors
New clinical concepts residing in ICD-10-CM should be identified and conveyed
Retired ICD-9-CM concepts
Expanded clinical specificity
Terminology changes
9 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
REASON 2 — To identify clinical documentation essentials ICD-10-CM MAPPING: REASONS, RULES AND RESTRICTIONS
New concepts/classification axes conveyed • Salter-Harris physeal fracture classification
system • Asthma classification • Categories of diabetes mellitus • Obstetrical trimester as secondary axis
of classification
Retired concepts/classification axes • Essential hypertension, malignant, benign,
unspecified • Obstetrical episode of care as secondary axis
of classification
Terminology revisions
Expanded clinical specificity • Anatomy and Physiology • Laterality: Left, Right, Bilateral
Intermediate Coronary Syndrome Unstable Angina
Septicemia Sepsis
Senile Cataract Age-Related
10 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
REASON 2 — To identify clinical documentation essentials ICD-10-CM MAPPING: REASONS, RULES AND RESTRICTIONS
• Identifying documentation needs concerning the clinical concepts and anatomical specificity for selected subset of codes
• Create training tools and modify templates
• Train providers, coders and other coded data users
Key Action Items
11 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
REASON 3
To evaluate software and coding resources
Key factors
Vendors apply software subjective decision logic and assumptions
Resources based on General Equivalence Mappings (GEMs) represent all valid alternatives, based on code descriptor information; not intended for all uses — not application-specific
Forms and reports represent coded facility-specific data requirements
12 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
REASON 3 — To evaluate software and coding resources ICD-10-CM MAPPING: REASONS, RULES AND RESTRICTIONS
Evaluate how well the software makes ‘good’ decisions based on: • Reasonable code translations of the code
(source code) • The “complete meaning” is based upon the
code set conventions and structure, coding guidelines, instructional notes, official coding advice, index entries and code descriptors
How does the software translate the following: • Coding of Injuries (800-900) in ICD-9-CM
is for initial encounter only; in ICD-10-CM 7th character defines the encounter; GEMs only map to “initial encounter” codes
• Aftercare vs. subsequent encounter issue: V54.16, Encounter for aftercare healing traumatic fracture of lower leg, maps to almost 4,500 ICD-10-CM alternatives
• The change in classification axis from outcome of delivery encounter to trimester
• ICD-10-CM utilizes terms such as dependence and abuse. ICD-9-CM utilizes the descriptors of continuous, episodic, in remission and unspecified
13 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
REASON 3 — To evaluate software and coding resources ICD-10-CM MAPPING: REASONS, RULES AND RESTRICTIONS
• Verify software decision logic
• Set decision-making parameters based on the specific data source and use
• Check training effectiveness
• Update forms, reports and analytics
Key Action Items
Rules
15 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
RULE 1
Use translations to facilitate conversion
Key factors Not “crosswalks” intended to be a 1:1 code match
May not provide complete clinical picture of coded data; based on code descriptor
Translations provide multiple alternative choices
Rules and assumptions applied not readily known
Not intended to be applied to all conversion needs
Key action items Identify the translated data use
Identify the source data used for the mapping
Identify the differences in clinical concepts, classification axes, coding practices and terminology for specific subset of codes
Develop selection criteria based upon facility-specific needs
16 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
RULE 2
Know coding guidelines and instructions differences and similarities
Key factors Structure and conventions changes
Classification axis revisions
Use additional code instructions
Application of appropriate guidelines
Key action items Start coding in the specific ICD-10-CM sections to identify issues
to be resolved
Identify the end use of the mapping data
Identify and resolve coding practice issues
Map according to coding in the target system
17 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
RULE 3
Use mappings bi-directionally
Key factors In some instances, one map may not include a code that is required
in coding a condition that is a combination code in one code set or the other
Glaucoma stages (365.70-365.74) have NODX forward map, yet backward mapping results in scenarios to accommodate the combination codes in ICD-10-CM
In some instances, one map may not include a code that is required in coding a condition or clinical concept that has been retired
Level of specificity difference between the code sets
Differences in the structure of the classification system
Key action items Identify the end use of the mapping data
Code “problem areas” in the coding conventions of the target system
Compare all results and document final decision logic assumptions
Restrictions
19 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Key factors Based upon code (description), no supporting/additional
information Translations are based on concept(s) inherent to one
code set (source) Mappings can take specific concepts to more general
concepts, but cannot add specificity when the original information is general
Key action items Identify the end use of the mapping data Code “problem areas” in the coding conventions
of the target system Compare all results before and after mapping
RESTRICTION 1
GEMs designed as translators of coded data
20 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Key factors GEMs provide all possible alternatives GEMs were not developed with specific application
decision logic GEMs not developed to reflect facility-specific data use
Key action items Identify the end use of the mapping data Establish decision logic criteria and assumptions Document final decision logic Compare all results before and after mapping
RESTRICTION 2
Designed for multi-purpose use
21 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Key factors GEMs will include “No Map” results Level of specificity difference between the code sets Differences in the structure of the classification system In some instances, one map may not include a code that
is required in coding a condition that is a combination code in one code set or the other
Key action items Analyze coding results before and after mapping Adjust coding practices to account for concept
differences Improve clinical documentation to minimize coding
accuracy issues Compare all results before and after mapping
RESTRICTION 3
Classification system concept differences
Assess your readiness
23 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Listed top high-volume code set
Coded in both code sets
Compared the coded results
Review those mappings that have conflicts
READINESS 1
Top coding issues identified
24 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Decisions must be made as to how to translate, which concept takes priority (reimbursement, clinical, etc.)
Test and revise assumptions and rules in decision making
Documented rules applied
READINESS 2
Set decision-making rules
25 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Develop procedures to review all changes periodically
Develop procedures to update applications of data
Refresh coding training
READINESS 3
Plan for changes
26 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
ICD-10-CM Mapping: Reasons, rules and restrictions
Reasons Rules Restrictions Readiness
• Coding training focus
• Clinical documentation improvement
• Software and resource evaluation
• Use mapping to
facilitate conversion
• Understand classifications system similarities and differences
• Use mapping bi-directionally
• Designed as
translators
• Designed for multi-purpose use
• Mappings can take specific concepts to more general concepts
• Identify top-priority
coding issues
• Resolve and set decision-logic
• Plan for change
Assess … educate … execute Successful implementation on October 1, 2014 Thank you.
CONTACT INFORMATION Anita C. Hart, RHIA, CCS, CCS-P ICD-9-CM and ICD-10-CM/PCS Product Manager AHIMA-Approved ICD-10-CM/PCS Trainer [email protected]
ICD-10 education: Strategic considerations for how to educate your organization
1 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Objectives Today’s topics and learning objectives:
Areas of impact: Identify the various areas of impact across your organization
Learner categories and educational needs: Plan when education should start for each
Educational program planning: Understand the specific educational needs and develop a training plan that takes all learning activities into consideration
Areas of impact
3 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Business impact areas
• Registration (central; ED; ambulatory; ancillary)
• Scheduling
• Admitting/discharge/ transfers
• Prior-authorizations/ pre-certifications
• Medical necessity checks
• Bed management
• Physician and nurse documentation
• Ancillary and support services documentation
• Order entry and results
• Workflow within EMR
• Case management
• Clinical research
• Workflow and transfers between clinical units
• Coding and abstracting
• Deficiency tracking
• Claim edit work lists
• NCCI/LMRP edits
• Encoding and grouping
• Physician query
• Clinical documentation improvement
• Charge entry
• Payer and clearinghouse edits
• Contracting
• Facility and professional billing
• Follow up and denial management
• Claims status
• Quality/outcomes reporting
• Financial/revenue reporting
• Public health reporting
• Clinical registries
• Data warehouse
• ICD-9 to ICD-10 mapping and translation
• Compliance
• Implementation of new business and/or clinical systems
• Transition to paperless environment
• Opening of new facility
• Narrowing of IT vendor portfolio
• Implementation of computer-assisted coding
Patient access Clinical and ancillary
Health information
management Patient financial
services Analytics and
reporting Strategic initiatives
Organizational Support: Project Management — Education and Training — IT
People Systems
4 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
ICD-10 transition methodology
Learner categories and educational needs
6 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Transitions learners from a structured learning environment to applying the knowledge obtained in Level 1/2 courses to their specific job function • Uses instance data from
the learner’s environment
Level 3: On-the-job
Learner categories: Skill building
Provides high-level education of ICD-10 mandate to ensure that the learner has baseline knowledge of why the industry is moving from ICD-9 to ICD-10 • Benefits • Challenges • Timeline • Impact to systems • Workflows
Delivers deeper understanding of the ICD-10 code set • Content will vary dramatically
by job function
Level 2: Knowledge-based/skill transfer
Level 1: Overview
7 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Learner categories: Roles
Learner categories Typical roles/credentials Education levels
Coders CCS, RHIA, RHIT, CPC, etc.
Revenue cycle, IT and reporting/analytics
Claims, appeals, referral/prior authorization, billing, patient accounts, analysts, report writers, etc.
Providers, nurses, CDI specialists
MD, NP, PA, ancillary providers, therapists, RN, case managers, CDI specialists, etc.
Executives/ key stakeholders
CEO, CFO, CIO, CCO, CNO, COO, CMO, CMIO, etc.
1
2
3
Level 1: Overview
Level 2: Knowledge-based/skill transfer
Level 3: On-the-job
1 2 3
1 2
1 2 3
1
8 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Prior Q3 2013 Q4 2013 Q1 2014 Q2 2014 Q3 2014
Executives/Stakeholders
Revenue Cycle
IT/Reporting
Coders/HIM
CDI Specialists
Providers/Nurses
Learner category: Timeline
* Depending upon dual-coding strategy
2
1
1
1
1
1
1 2
2*
2 3
3 2
To prepare for report remediation
Com
plia
nce
O
ctob
er 1
, 201
4
2 3
1
2
3
Level 1
Level 2
Level 3
2 3
2 3
2 3
Education program planning
10 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Education program planning: Holistic education
ICD-10 education program
Consider education/training program coordinators or overall program management
Consider both eLearning and instructor-led content to provide a comprehensive and multifaceted program
Can you integrate your eLearning courses and content into your existing or pending technology, including CAC, CDI, mobile coding apps, etc.?
Program management
Content
Technology and integration
11 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Education program planning: Strategy and philosophy
• Focus on the void/delta to meet the learner’s need • Offer flexibility in delivery methods
Inform without extraneous components
• Understand organizational needs • Leverage partnerships
Partner with the best | Use resources wisely | Use expertise wisely
Concise
Relevant
Accurate
Focus on learner retention
12 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Education program planning: Key decisions
• Understand the needs across your entire organization
• Make it informative and relevant for the job role
• Determine strategy for employed vs. non-employed
• Address community physicians/other hospitals in the area
• Determine testing/attest requirements for each role
• Plan remediation/1:1 support for inadequate assessment results
• Determine delivery methodology that makes sense for each learner category
• Develop a dual-coding strategy (will impact the timeline)
Education must be concise, relevant and accurate
13 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Educational program planning: Methodology for physicians
• Includes both employed/non-employed providers • Focus is on acute-care clinical documentation requirements
All affiliated providers
• Includes employed providers within medical group • Focus is on documentation and coding requirements in the physician
practice (professional) setting
Employed providers only
• Includes all non-employed community providers affiliated with the hospital • Focus is on awareness/education of both impacts and potential
remediation activities
Community providers
14 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Educational program planning: Focus on provider needs
Focus on provider documentation What they need to know to document properly
Identify relevant concepts in documenting They need to know what to document, not how to code
Emphasize the differences from ICD-9 to ICD-9 Some documentation concepts are identical, others are not
Teach only the differences Providers do not need or want to be taught what they already know
15 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Educational program planning: Interaction is important
Leverage train-the-trainer sessions Peer-to-peer education has proven to be the most effective
Identify physician champion(s): • Conduct education sessions at dept. meetings,
physician forums, physician lounge, etc. • Provide one-on-one coaching to “repeat offenders” • Be ICD-10 SME to physician community
Integrate with existing CDI programs
Prioritize education High-volume/high-impact diseases
Offer CME credits
16 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Support physicians with technology: EMR tools
Getting documentation from here … … to here
Appropriate use of technology: electronic templates | prompts | pick lists
17 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Questions? Thank you.
Concurrent CAC with computerized CDI at UPMC: Lessons learned from implementation University of Pittsburgh Medical Center UPMC | Technology Development Center
2
• Explain the CDI challenge at the University of Pittsburgh Medical Center (UPMC)
• Identify how technology can improve the CDI process
• Describe how a natural language processing (NLP)-driven CDI can enhance staff productivity, coding accuracy and compliance
• Highlight lessons learned and opportunities discovered from CDI implementation
• Review the transition from post-discharge CAC to concurrent CAC
Objectives
Presenters
JULIE TRUVER MSIS, RHIA Vice President, Operations UPMC | Technology Development Center
ADELE TOWERS MD, MPH Medical Director UPMC Health Information Management
Quick facts — University of Pittsburgh Medical Center
National leader UPMC is one of the leading nonprofit health systems in the United States, headquartered in Pittsburgh, Pennsylvania.
Employer UPMC is Western Pennsylvania’s largest employer, with more than 56,000 employees, including 3,200 physicians.
Inpatient facts Hospitals – 22 (Academic, Community and Specialty) Outpatient Facilities – 400 Average Daily Census – 3,250 Inpatient Discharges per Year – 253,000 Surgeries per Year – 174,000 ED Visits per Year – 600,000
5
• No concurrent CDI program in place
• 100% retrospective focus on record review
• Average of 550 inpatient medical records per day are coded
• 5% of the total discharges result in a query with revenue impact of $1M per month
• Creating, distributing, monitoring and resolving physician queries is labor intensive
• Queries that are not resolved quickly impact the DNFB
CDI at UPMC: The challenge
CONCURRENT
100% RETRO
5% = $1M/mo.
550 records/day
6
Staffing per the financial benchmarking report
Source: “Best-in-Class Clinical Documentation Improvement Programs.” Financial Leadership Council — The Advisory Board Company. 2010.
Performance LOW AVG HIGH
Total Beds Covered per CDI FTE
128 113 92
Total FTEs Required for 4,732 Beds
37 42 51
Salary Benefits Total
$2.7M $3.1M $3.8M
Assumptions: • Total Beds Provided from UPMC Finance
• Average Salary for CDIs $28.84/hour per Indeed.com
• Salary marked up 22% to add benefit costs to total salary $35.18/hour
• FTE of 2,080 hours per year
7
ICD-10 impact on productivity and revenue
$3.1M $3.8M
$8.1M
Productivity Denials Financial Impact Undercoding
Projected annual financial impact of ICD-10: UPMC Health System: 4,500 Licensed Beds
CAC Key CDI Key
Content derived from The Advisory Board Company. 2013
Balancing organizational approach with physician needs
HOSPITAL PHYSICIANS
DNFB SIMPLE
Clinically Relevant Concurrent
FTE-Neutral
Case Mix Index
Severity of Illness Risk of Mortality
Alerts within Workflow
Requirements for technology solution
10
The CDI case-finding conundrum
• Reviewing enough charts • Reviewing the right charts • Reviewing charts for the right reasons • Reviewing charts enough times
Reviewing enough of the right charts for the right reasons enough times
Appropriate Case Finding
11
ACDIS CDI Staffing Survey*:
• CDI specialists conduct 8 to 12 new reviews per day
• Each CDI specialist spends between 33 and 48 minutes per initial review
Case finding is often a wasted effort
*Source: ACDIS CDI Work Group. White Paper: CDI staffing survey provides estimates on record reviews, productivity considerations. HCPro, Inc., 200 Hoods Lane, Marblehead, MA. 2010
Percent of Reviews Resulting in a Query
Percent of Respondents
0–10% 7% 11–20% 22% 21–30% 36% 31–40% 15% 41–50% 7% 51–60% 6% 61–70% 2% 71–80% 2% 81–90% 1% 91–99% 0% 100% 0%
TOTAL 100%
87% of respondents <50% of reviews result in a query 36% of respondents 2 out of 3 reviews unnecessary
System-built queries vs. manually built
13
Types of documentation queries
Example 1: Specificity Example 2: Clinical Clarity
Physician documents “CHF improving.” Physician documents “fluid retention and shortness of breath improving.”
Physician Documentation • “CHF” in History and Physical • “CHF” in Progress Note • Code for Unspecified CHF
Clinical Indicators • Pulmonary Vascular Congestion in CXR • Ejection Fraction of <30% in Echo • BNP of 700 • IV Lasix in MAR
Approach to Query • Engage Physician to Provide
Specificity in CHF Diagnosis – Acute vs. Chronic – Diastolic vs. Systolic – Acute or Chronic
Approach to Query • Engage Physician to Clarify Clinical Facts • Ascertain if there is a diagnosis that could be added to reflect the clinical
picture for treatment of this patient • Subsequent query for specificity in diagnosis, if indicated
The reason we need a CDI program is to assist physicians when they do not document something well OR when they neglect to mention a diagnosis or condition at all.
14
Common ways physicians downplay severity of illness
We document … We SHOULD Document …
Urosepsis UTI with Sepsis
“Wet,” “CHF,” “rales, give Lasix” Acute Systolic CHF (or Diastolic, etc.)
Troponin Possible SEMI
H/H Acute Blood Loss Anemia
Dry, Creat Dehydration, Acute Kidney Injury
15
Physician documentation
Impression: 1. Urosepsis 2. CHF-IV Lasix 3. Pleural Effusion
Impression: 1. Sepsis d/t UTI 2. CHF-IV Lasix 3. Pleural Effusion
Impression: 1. Sepsis d/t UTI 2. Acute on Chronic Diastolic
Heart Failure 3. Pleural Effusion
80-year-old female, fever, AMS, dysuria and elevated white count, CXR pulmonary shows vascular congestion
MS-DRG MS-DRG RW SOI ROM MS–DRG $
690 0.7810 1 1 $4,842
Note: Severity and Mortality are both level 1
MS-DRG MS-DRG RW SOI ROM MS-DRG $
872 1.0988 2 2 $6,812 Note: Severity and Mortality levels increased to 2 and RW increased to 1.0988 by documenting the Sepsis d/t UTI. Reimbursement increased.
MS-DRG MS-DRG RW SOI ROM MS-DRG $
871 1.8803 3 3 $11,657
Note: Severity and Mortality levels remained at 3 and RW increased to 1.8803 by documenting the Sepsis d/t UTI and Acute on Chronic Diastolic Heart Failure. Reimbursement increased.
16
Physician query
17
Physician query
18
Physician query
19
Physician query
20
OptumTM CDI — Hard ROI
$1.8M $2.2M $2.3M $2.4M $3.5M
$4.3M
$2.7M $2.2M
$21.5M
$1.0M $0.8M
$1.0M $1.0M
$1.2M $1.2M $1.2M
$1.1M $1.1M
$1.3M $1.4M
$1.3M
$1.7M
$1.8M
$2.0M
$2.2M
$10.2M
$11.3M
$69,000 ÷ 500 cases = $138/case
83% of cases found by Optum CDI module
Existing manual program
Incremental revenue after CDI marker validation
$28K
$41K
$69K
Impact of more accurate documentation
UPMC Case Study Projected Annual Income $21.5M
3 Facility 6 Month Limited Pilot Increase in revenue of $4.5M
Presbyterian 31,133
McKeesport/ Horizon/
Northwest 19,315
Mercy 16,669
Hamot 16,279
St. Margarets 13,378
Passavant 16,311
Magee 17,470
Shadyside 25,322
All UPMC 155,877
21
DRG impact
316
243
107
20 8 18 4
81
366
99 62 51 35 22
A (<1) B (1-2) C (2-3) D (3-4) E (4-5) F (5-6) G (>6)
DR
G C
ount
DRG Weight Scale
Original DRG Weight
New DRG Weight
CDI codes consistently and accurately. This shifts originally coded cases to higher DRGs due to severity.
• Physician satisfaction with query process – Within workflow; requiring little hand-holding
or follow up – Focus beyond revenue cycle
• SOI/ROM Lever
• Confidence in ICD-10 preparation – Ability to measure and monitor performance – Rules engine provides safety net
• Staff satisfaction – Improved communication among physicians,
CDIS and HIM coders
• Administrative oversight and agility to act
Soft ROI
Questions? Thank you.
ICD-10 physician education: Engaging your physicians for a smooth transition
1 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Objectives Today’s topics and learning objectives:
Create focused training
Support physicians with technology
Integrate CDI processes into ICD-10 strategies
Create focused training
3 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Educational program planning: Strategies
Education needs to focus on specifics and not generalities
Eliminate the fear Emphasize only the differences from ICD-9 to ICD-10
Identify relevant concepts in documenting They needs to now what to document, not how to code
Minimize additional workflows/processes Utilize tools instead of provider time to get things done
Make education time appropriate Not all specialties require the same amount of training
4 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Create focused training: Delivery
Make education a priority
Select a content partner with flexible curriculum
Determine appropriate delivery channel eLearning vs. instructor-led or a combination
Instructor-led eLearning
Support physicians with technology
6 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Support physicians with technology: Analytics
Prioritize educational focus with analytics Identify high-volume/high-impact diseases • Hospital inpatient: Identify potential impact to reimbursement • Hospital outpatient: Identify high-impact codes moving from ICD-9 to ICD-10
CODING & REIMBURSEMENT IMPACT/RISK IDENTIFICATION
7 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Support physicians with technology: EMR tools
Getting documentation from here … … to here
Appropriate use of technology: electronic templates | prompts | pick lists
8 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Support physicians with technology: Portable tools
Put information in physicians’ hands
Mobile applications providing: • Physician Documentation Guidelines • Automatic monthly updates • Mapping content • User notes • Favorites
Job aids Flash cards with top 10 diagnosis by specialty
Reference material
Integrate CDI processes into ICD-10 strategies
10 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Integrate CDI processes into ICD-10 strategies
Mitigate risk + leverage opportunity = CDI a must for ICD-10
Primary objectives Critical success factors
• Improve physician documentation
• Improve Case Mix Index (CMI)
• Enhance compliance
• Document for appropriate reimbursement
• Identify and track core and other quality measures
• Executive sponsor and accountability
• Physician liaison
• Robust reporting and metrics
• Adequately trained clinical documentation specialists
• Effective physician query process
11 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Integrate CDI processes into ICD-10 strategies
• Effective documentation standards
• Severity-adjusted documentation practices
• Demonstrate how documentation improvement opportunities support professional billing and reporting of patient acuity (severity of illness and risk of mortality)
• Case scenarios that illustrate differences in improved documentation — from both a clinical/quality and reimbursement perspective
Education options
• Digital videos (4 to 8 minutes) on each of the CDI markers presented by specialists
• Onsite or webinar instructor-led
• CBT learning
12 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Summary
• Think BIG ― ICD-10 changes more than the codes for providers
• Focus training • Leverage technology • Integrate with other initiatives
Data Action Accountability
13 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Questions? Thank you.
Susan Hoyle, CCS | Coding Manager, IP/Obs
Concurrent coding with CAC helps Mission Health improve physician relationships
About Mission Health • Based in Asheville, North Carolina
• North Carolina’s sixth largest health system
• Tertiary care regional referral center for Western North Carolina and adjoining region
• Main hospital: 730 beds on two adjoining campuses
• Medical staff includes more than 750 physicians
• 6,000 employees and nearly 700 volunteers
• Centers of excellence include Pediatrics, Cancer, Heart, Neurosciences, Orthopedics, Women’s Health, and the region’s dedicated Level II Trauma Center
The move to computer-assisted coding • Primary Driver: ICD-10 ‒ Mitigate coding productivity loss ‒ Prepare for limited coding resources
• Ensure appropriate revenue/reimbursement ‒ Capture all codes that may impact DRG/Case Mix Index ‒ Reduce DNFB
CAC helped enable Mission Health’s concurrent coding • CAC reviews all text documents, including electronic notes progress notes
• Natural Language Processing (NLP) ‒ The brains of the CAC system ‒ Review electronic documents and suggests codes in near real-time ‒ NLP technology that can “understand” medical terminology and context is
recommended
The move to concurrent coding • Originally to encourage physicians to use electronic progress notes
• Benefits for physicians ‒ Use the progress notes to provide codes for physician billing ‒ Identify situations where their documentation could be improved ‒ Increase concurrent queries while reducing post-discharge queries
Benefits of concurrent coding • Coding queries to physicians have resulted in $297,000 average increase per
month in DRG reimbursement over the same three months in 2012
• Discharge Not Final Coded >5 days for Inpatient and Observation cases has decreased 30% from $6.9 million to $4.3 million
• Clinical Documentation Specialists have been able to increase their review of cases by 43%
• Diagnosis codes are being used to generate system alerts to physicians to drive treatment protocols (example: AMI and no aspirin) tied to quality indicators and the value-based purchasing program, reducing “false alarm” alerts by more than 5000%. Prior to concurrent coding, these alerts were firing off of clinical indicators that were typically “false alarms”
Benefits of concurrent coding • The calculation of a working DRG at admission is providing an estimated LOS
for Care Managers, resulting in a decrease in unnecessary chart reviews
• The calculation of a working DRG is allowing for identification and prioritization of discharge planning on cost outlier cases
• Implementation of ICD-10 will result in the need for greater documentation specificity. Concurrent coding will identify these documentation needs early on in the admission, generating concurrent queries to the MD. Providing that feedback to the MD prior to ICD-10 implementation will position Mission for a more successful ICD-10 implementation
Queries: Financial impact $550,000
$500,000
$450,000
$400,000
$350,000
$300,000
$250,000
$200,000
$150,000
$100,000
$50,000
$0 J F M A M J
Financial Impact from MD Queries
FY13
FY12
Case mix index
1.58
1.6
1.62
1.64
1.66
1.68
1.7
1.72
1.74
October November December January February March April
FY 2013
FY 2012
Average FY 2012 CMI: 1.6542
Average FY 2013 CMI (through seven months) : 1.6943
2012–13 increase: 2.4%
Thank you
Radical thinking…“Let’s let doctors be doctors”
Supportive physician communication
Providing time-of-service support for clinical documentation improvement Supporting physicians in this rapidly changing environment
Why now?
In the current environment, it is imperative that the medical record completely capture an accurate reflection of the patients SOI, ROM and all treatments rendered.
The perfect storm on the horizon
• Pay for performance
• Accountable Care Organizations (ACO)
• ICD-10, arriving October 1, 2014
• Denials
• Changes in reimbursement
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• Optum CAC/CDI Single solution will facilitate the uniform efficient routing of cases for those conditions that are undocumented or need to be specified more clearly in the medical record.
• Currently, our competitors rely on the clinician’s individual knowledge and ability to search through the records in a random method to find relevant clinical elements.
Solutions
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Optum Enterprise CAC: A comprehensive coding solution
Enterprise CAC • Powered by LifeCode NLP technology, suggests and assigns traceable codes for coder review.
• Unifies hybrid medical records by presenting the coder with one consolidated view of the case, including all electronic medical records and scanned image documentation.
• Provides a comprehensive play for for all hospital inpatient and outpatient coding needs within a single integrated solution.
• Dashboard view for managers’ full transparency of coding operations.
Coding & Reimbursement Module • Logic- and book-based encoder
includes all supporting encode components, clinical references, edicts, reimbursement library an coding and reimbursement.
• When paired with Enterprise CAC, a fully integrated product for all coding needs within one single solution.
Workflow Module • Automates case
assignment.
• Reduces steps in coding processes.
• Build and maintain work queues.
CDI Module • Automates the entire CDI process, including
clinician query.
• Includes traceability of colder and CDI specialist efforts for improved communications and tracking.
• Provides the opportunity to address any documentation issues to support quality and coding efforts much earlier in the workflow.
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Ease transition to ICD-10 • Helps mitigate anticipated reduction in
productivity (and resulting revenue cycle impact)
Increase coder productivity • Reduce or eliminate coding backlogs, overtime
and contract coding services dependencies
Improved coding accuracy • Identify and capture ICD-9-CM and CPT® codes
based on clinical documentation • Correctly capture Case Mix Index (CMI) • Decrease external audit dependency and costs
Increased revenue and reduced expenses • Shorten revenue cycle • Decrease number of denials and re-bills • Reduce administrative costs
More consistency • Less room for coder interpretation • Improve quality of less experienced coders
bridging the coder experience gap
Traceability • Complete traceability of codes to document
for internal and external auditing • Unifies hybrid records
Optum Enterprise CAC benefits
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• Clinically invalid queries • Ever changing regulatory landscape • EMR • Opportunity/case finding challenges • Clinical verbiage vs. CMS verbiage • Physician time for education • Variable coder and CDIS knowledge base
Current challenges
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Connected functions/processes are critical to success
Coding and CAC
ICD-10 Meaningful Use
CDIP and CDI technology
Education and feedback drives improved clinical documentation
Clinical documentation allows for: • Increased specificity and accuracy • Better compliance, patient safety • Typically increases CMI • Increases quality report card • Drives accurate coding
Computer-assisted coding enables: • Increased accuracy and efficiency • Mitigate ICD-10 productivity impact
Both clinical documentation and coding with be impacted by ICD-10 and require organization-wide education and intersect with Meaningful Use initiatives
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NLP LifeCode case finding
CDI markers
Integrated solution with coding
Configurable worklist
Consistent query process/templates
Functionality
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• Most accurate case finding in the industry • Use of the LifeCode NLP engine • Automates case finding/routing • Standardizes the query process • Embedded clinical references in the query process • One-step query creation to the physician
CDI solution
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• The integrated solution with the coders allows the same query solution to be launched both in the concurrent and post discharge environment
• The same query method and embedded clinical references are utilized for consistency to the providers
Integration with coding
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Process improvement
This is a demonstration of a typical workflow
Physician process CDI specialist Coder
• Document clinical findings
• Review queries routed directly to appropriate physician
• Add requested response/specificity information to the chart
• Review charts with CDI markers
• Send queries as appropriate
• Monitor for query response
• Ensure case is optimized if able, prior to reaching coder
• Review optimized cases
• Send query if needed using same process
• Send final bill
• Minimal DNFB due to concurrent process
Thank you.
Contact information: Lynn Probert , RN CDI Product Specialist Cecilia Guardiola, Associate Director, CDI Consulting [email protected] [email protected]