Introduction Value-Based Purchasing Claims … Measurement Source Mortality AMI CHF PNA Claims The...

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Enhance the Value of Your CDI Program Under Value-Based Purchasing

FTI Consulting, Inc.:Shannon Newell, RHIA, CCS, AHIMA-Approved ICD-10-CM/PCS Trainer; Director

Andrew Rothschild, MD, MS, MPH, FAAP, CCDS, CDIS, AHIMA-Approved ICD-10-CM/PCS Trainer (*Recertifying/credentialing); Director

Purchasing

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Introduction Value-Based Purchasing

Outcomes Measurement SourceMortality AMI

CHFPNA

Claims

The “Outcomes Domain” of Hospital Value-Based Purchasing comprises 30% of performance. The mortality and PSI (patient safety indicator) metrics are derived from ICD-9-CM codes submitted on claims.

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PNA

Serious Complications PSI #90* Claims

CLABSI CDC

*The composite measure which consists of following PSIs:#3 (pressure ulcer)#6 (iatrogenic pneumothorax)#7 (CLABSI)#8 (postop hip fx)#9 (postop hemorrhage or hematoma rate)*#10 (postop physiologic and metabolic derangement)*#11 (postop respiratory failure rate)*#12 (postop PE or DVT)#13 (postop sepsis)#14 (postop wound dehiscence)#15 (accidental puncture or laceration)*Not NQF endorsed

IntroductionClaims-Based Value Initiatives

Clinical documentation improvement programs can impact claims-based metrics

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The train has left the station … claims-based value initiatives continue to grow:• Value-Based Purchasing Program (VBPP)• Hospital Readmission Reduction Program (HRRP)• Hospital-Acquired Conditions (HAC)

VBPP HRRP HAC Total

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VBPP1.5%

VBPP1.75%

VBPP2%

HRRP3%

HAC1%

HRRP3%

HAC1%

HRRP3%

HAC1%

Total5.5%

Total5.75%

Total6%

FY 2015

FY 2016

FY 2017


A variety of risk adjustment models are utilized for claims-based metrics – CDI programs must become increasingly sophisticated to capture documentation

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Learning Objectives

• Describe CMS claims based metrics included in the Value Based Purchasing Program (VBPP) and the Hospital Readmission Reduction Program (HRRP)

– Data definitions

– Severity/risk adjustment methodologiesy j g

– Resources for further study

• Discuss the impact of readmission, mortality and patient safety indicator outcomes on hospitals

• Use VBPP principles to:

– Chart review strategies and queries

– Performance metrics which measure and guide CDI program efforts

– Projects to systemize documentation capture7

HOSPITAL-ACQUIRED CONDITIONS (HAC) • The Accountable Care Act (ACA) contains language supporting payment

reductions of 1% in 2015 for hospitals with HAC rates in the top quartile (25%) relative to national average1

HACs

• 1 ACA PLAW-111pub148• CMS HAC: http://tinyurl.com/bzkb3ry

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HACs

• HAC data definition specifications are provided on the CMS site

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HAC Fact Sheet: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-payment/HospitalAcqCond/downloads/HACFactsheet.pdf

Readmission & Mortality

Readmission and Mortality Outcomes – CHF, AMI, pneumonia• Financial penalties for excess readmissions (Hospital Readmission Reduction

Program [HRRP]) and mortality rates (Hospital Value-Based Purchasing [HVBP])

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QualityNet is the “go-to” site for detailed information on readmission and mortality metrics

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Key sections to review: “Measure Methodology,” “Resources”• “Resources” includes information on SDx which impact risk adjustment• “CC” = Clinical Categories

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SDx Clinical Category ICD-9-CM Codes Mapped to “CC”

COPD CC 108Renal failure CC 131Diabetes & DM CC 15-20, 120

Key sections to review: “Measure Methodology,” “Resources” (cont.)

40301Mal hyp kid w cr kid V 131Renal Failure40311Ben hyp kid w cr kid V 131Renal Failure40391Hyp kid NOS w cr kid V 131Renal Failure40402Mal hy ht/kd st V w/o hf 131Renal Failure40403Mal hyp ht/kd stg V w hf 131Renal Failure40412Ben hy ht/kd st V w/o hf 131Renal Failure

compMI CC 81

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40412Ben hy ht/kd st V w/o hf 131Renal Failure40413Ben hyp ht/kd stg V w hf 131Renal Failure40492Hy ht/kd NOS st V w/o hf 131Renal Failure40493Hyp ht/kd NOS st V w hf 131Renal Failure5845Ac kidny fail, tubr necr 131Renal Failure5846Ac kidny fail, cort necr 131Renal Failure5847Ac kidny fail, medu necr 131Renal Failure5848Acute kidney failure NEC 131Renal Failure5849Acute kidney failure NOS 131Renal Failure

5851Chro kidney dis stage I 131Renal Failure5852Chro kidney dis stage II 131Renal Failure5853Chr kidney dis stage III 131Renal Failure5854Chr kidney dis stage IV 131Renal Failure5855Chron kidney dis stage V 131Renal Failure5856End stage renal disease 131Renal Failure5859Chronic kidney dis NOS 131Renal Failure586Renal failure NOS 131Renal Failure

75314Polycyst kid-autosom rec 131Renal Failure

Risk adjustment utilizes:• Codes from Part A and Part B claims for the prior 12 months• “Comorbid” codes only if present at the time of the index admission


Source: QualityNet.org – NQF Specifications Manual for National Hospital Inpatient Quality Measures Discharges 01-01-13 (1Q13) through 12-31-13 (4Q13). QualityNet 14

CHF Risk-Adjusted Mortality

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CHF Risk-Adjusted Readmissions

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CHF Risk-Adjusted Readmissions

• “ACS” is assigned to Clinical Categories 81 and 82 which encompass AMI and unstable angina. Excerpt:

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Case Study

• The risk-adjusted mortality rate for Hospital P’s AMI patients is 50% higher than expected

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Case Study

• 79 yo male with chronic systolic heart failure, CAD, COPD• Presented w/ increased dyspnea, tachypnea, +3 pitting edema,

chest discomfort, cough• EKG unchanged, Q-wave abnormalities c/w prior MIs• Cardiac troponin >99th percentile x1, now decreasingp p g• Echo: RVH, pulmonary artery HTN, LVEF, EF 30%• Nursing: “Coccyx with nonblanchable redness with skin tear x2”• Discharge summary Dx:

1. Exacerbation of systolic HF with troponin leak2. COPD exacerbation

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Case Study Query – NSTEMI

• Query to clarify whether the patient had an NSTEMI• Acute decompensation of chronic systolic HF with a “troponin leak”? or• Acute decompensation of chronic systolic HF with an NSTEMI?

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Were the elevated troponin levels indicative of NSTEMI?

N Engl J Med 2008; 358:2117-2126 May 15, 2008 DOI: 10.1056/NEJMoa0706824 http://www.nejm.org/doi/full/10.1056/NEJMoa0706824



• Troponin elevations in acute heart failure indicate poor prognosis• Especially with ultra-sensitive test, providers (cardiologists) must

indicate clinical significance, or relevance, of results

Outdated

• Peacock, W.F., et. al. Cardiac troponin and outcome in acute heart failure. N Eng J Med 2008;358:2117–2126.

• Horwich, T.B., et. al. Cardiac troponin I is associated with impaired hemodynamics, progressive left ventricular dysfunction, and increased mortality rates in advanced heart failure. Circulation 2003;108:833–838.

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• Definition of myocardial infarction—criteria for acute myocardial infarction– Evidence of myocardial necrosis in a clinical setting consistent with acute myocardial

ischaemia

– Any one of the following criteria meets the diagnosis for MI:

• Detection of a rise and/or fall of cardiac biomarker values [preferably cardiac troponin(cTn)] with at least one value above the 99th percentile upper reference limit (URL) and with at least one of the following: g

– Symptoms of ischaemia

– New or presumed new significant ST-segment—T wave (ST—T) changes or new left bundle branch block (LBBB).

– Development of pathological Q waves in the ECG.

– Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality.

– Identification of an intracoronary thrombus by angiography or autopsy.

*Note that four other AMI criteria (outside the scope of this presentation) are defined; and that only one criterion must be satisfied to meet the definition.

Source: Thygesen, K., et al. Circulation 2012;126:2020–2035. 22


• AMI can be considered if:– Evidence of myocardial necrosis

(heart muscle cell death)– Clinical scenario consistent with MI– One of five criteria are met from the universal

definition of MI (prior slide)definition of MI (prior slide)• Criterion: Biomarker (e.g., cardiac troponin):

– Should be rising or falling and– Should reach >99th reference percentile and– One of the following is present:

• Symptoms of ischemia• New significant ST changes or new LBBB• Pathological Q waves• Imaging with loss of myocardium or wall motion abnormality• Intracoronary thrombus on angiography or autopsy

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By Cafer Zorkun; Open WikiDoc license: creativecommons.org/licenses/by-sa/3.0

Myocardial necrosis

Case StudyQuery – NSTEMI

• If NSTEMI, is the NSTEMI (or the CHF) the principal diagnosis?

Process Measures AMI-1 Aspirin at ArrivalAMI-2 Aspirin Prescribed at DischargeAMI-3 ACE/ARB Inhibitor

Outcome Measures MORT-30-AMI Acute Myocardial Infarction

(AMI) 30-Day Mortality Rate

MORT-30-HF Heart Failure (HF) AMI-4 Adult Smoking Cessation Advice/CounselingAMI-5 Beta Blocker Prescribed at DischargeAMI-7a Fibrinolytic Therapy Received

Within 30 Minutes of Hospital ArrivalAMI-8a Primary PCI Received Within 90 Minutes of

Hospital ArrivalHF-1 Discharge InstructionsHF-2 Evaluation of LVS FunctionHF-3 ACEI or ARB for LVSDHF-4 Adult Smoking Cessation Advice/Counseling

( )30-Day Mortality Rate

MORT-30-PN Pneumonia (PN) 30-Day Mortality

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ICD-10-CM AMI

• ICD-10-CM impact – documentation requirements for AMI

Documentation Requirement

ICD-9-CM ICD-10-CM/PCS

Type of MI • STEMI (Q wave, transmural),• NSTEMI (non Q wave,

t l b d di l)

Same except unspecified defaults to STEMI

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nontransmural, subendocardial)• Unspecified

Acute MI time frame

Acute = < 8 weeks; considered initial episode of care

Acute = <4 weeks (28 days); episode of care not recognized–just time frame

Subsequent episode of care

Use of treatment provided to AMI after acute time period

Episode of care not recognized–just time frame. If >4 weeks, coded as new acute MI.

Subsequent acute MI

Treated as new acute MI Unique category for second+ acute MI; may be PDx/SDx; must also assign initial AMI code

ICD-10-CM AMI

• ICD-10-CM impact – documentation requirements for AMI (cont.)

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ICD-10-CM AMI

• ICD-10-CM impact – documentation requirements for AMI (cont.)

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ICD-10-CM AMI

• ICD-10-CM acute MI decision tree

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• AMI not further specified as NSTEMI or STEMI defaults to STEMI (Source: ICD-10-CM OCG)• No documentation of time frame defaults to initial (Source: ICD-10-CM Index – duration of <4 weeks

nonessential modifier)• I-10 code exists for initial/subsequent STEMI not further specified re: wall/artery (121.3, 122.9)


ICD-10-CM AMI

• ICD-10-CM acute MI decision tree (cont.)

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ICD-10-CM AMI

AMI query form – key content:• Time frame since event: __ <28 days (4 weeks) __ < 8 weeks ___Unknown

• Type: STEMI or NSTEMI (unspecified type defaults to STEMI)

• If STEMI, please provide wall site and artery*

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Case Study

• 79 yo male with chronic systolic heart failure, CAD, COPD

• Presented w/ increased dyspnea, tachypnea, +3 pitting edema, chest discomfort, cough

• EKG unchanged, Q-wave abnormalities c/w prior MIs

C di i 99 h il 1 d i• Cardiac troponin >99th percentile x1, now decreasing

• Echo: RVH, pulmonary artery HTN, LVEF, EF 30%

• Nursing: “Coccyx with nonblanchable redness with skin tear x2”

• Discharge summary Dx:

1. Exacerbation of systolic HF with troponin leak

2. COPD exacerbation

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Case StudyQuery – Old MI

• Query to clarify the diagnosis causing the Q-wave abnormalities

Criteria for prior myocardial infarction

Any one of the following criteria meets the diagnosis for prior MI:

P th l i l Q ith ith t t

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Photo by Peter Anderson, DVM, PhD, U. of Alabama at Birmingham, Dept. of Pathology Open WikiDoc license: creativecommons.org/licenses/by-sa/3.0

Myocardial necrosis at site of AMI

Pathological Q waves with or without symptoms in the absence of non-ischemic causes

Imaging evidence of a region of loss of viable myocardium that is thinned and fails to contract, in the absence of a non-ischemic cause

Pathological findings of a prior MI

Copyright American Heart Association

Thygesen, K., et al. Circulation 2012;126:2020–2035.


AHRQ Quality IndicatorsPSIs & IQIs

Patient Safety Indicators (PSI) and Inpatient Quality Indicators (iqi)• AHRQ: Federal agency for healthcare research – quality, costs, outcomes, patient safety • PSIs focus on potentially avoidable complications and iatrogenic events (adults, hospital)

PSI # 90 is a “composite” metric included in the 2015 VBPP and is comprised of the following PSIs

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p g

*The composite measure which consists of following PSIs:#3 (pressure ulcer)#6 (iatrogenic pneumothorax)#7 (CLABSI)#8 (postop hip fx)#9 (Postop hemorrhage or hematoma rate)#10 (Postop Physiologic and Metabolic Derangement)#11 (Postop Respiratory Failure Rate)#12 (postop PE or DVT)#13 (postop sepsis)#14 (postop wound dehiscence)#15 (accidental puncture or laceration)


• PSI data definitions can be located on the AHRQ website:

34• AHRQ: http://tinyurl.com/3pq7jp8


• An example of a data definition – PSI #13 (Postop Sepsis):

35AHRQ: http://tinyurl.com/3pq7jp8


• Inpatient Quality Indicators (IQI) focus on inpatient mortality for selected conditions and procedures (adults, hospital setting)

IQI #91

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Will be removed in future Hospital Compare updates. Source: CMS Final Rule IPPS 2013.

IQI #19

IQI #15

IQI #16

IQI #17

IQI #18

IQI #29



IQIs and PSIs use different risk adjustment methodologies:• IQIs utilize the APR-DRG classification system • The PSIs use an AHRQ risk adjustment methodology (below)• AHRQ will move to a single method for all of the QIs in the future

PSI #3 – Pressure Ulcer

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Table 2Definitions of Comorbidities

ICD-9-CM Diagnosis Codes

Discharge Does Not Have these Pre-V29 DRGs

8. Chronic pulmonary disease

490–492.8, 493.00–493.92, 494–494.1, 495.0–505, 506.4

COPD asthma 190–192, 202–203

AHRQ: http://tinyurl.com/accdpd6; http://tinyurl.com/at3jhpkHCUP: http://tinyurl.com/bg4oh2h

AHRQ PSI #90 CompositePSI #3 – Pressure Ulcer

Also a HAC –triple

indemnity?

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* Pressure ulcer stage “unstageable” is included in PSI #3 (not true for HAC)* Pressure ulcer capture is risk adjusted in PSI #3 (not true for HAC)

AHRQ PSI #90 Composite PSI #3 – Pressure Ulcer

Comorbidity Category examples:

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Case Study

• 79 yo male with chronic systolic heart failure, CAD, COPD

• Presented w/ increased dyspnea, tachypnea, +3 pitting edema, chest discomfort, cough

• EKG unchanged, Q-wave abnormalities c/w prior MIs

C di i 99 h il 1 d i• Cardiac troponin >99th percentile x1, now decreasing

• Echo: RVH, pulmonary artery HTN, LVEF, EF 30%

• Nursing: “Coccyx with nonblanchable redness with skin tear x2”

• Discharge summary Dx:

1. Exacerbation of systolic HF with troponin leak

2. COPD exacerbation

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Case StudyQuery – Skin Ulcer

• Query for diagnosis reflective of nursing note of “Coccyx with nonblanchable redness with skin tear x2”

– Pressure (decubitus) ulcer?

– Non-pressure skin ulcer?p

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Case StudyQuery – Pressure Ulcer

Stage/Description MS-DRGMCC

HACif not POA

PSI 90

CMSRiskAdjust

Stage 1 – Intact skin w/localized non-blanchable rednessusually over boney prominence

No No No Yes

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Stage 2 – Partial thickness loss of dermis, shallow open ulcerwith a red-pink wound bed or blister

No No No Yes

Stage 3 – Full thickness skin loss. Subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed

Yes Yes Yes Yes

Stage 4 – Full thickness with exposed bone, tendon or muscle Yes Yes Yes Yes

Unstageable – Stage cannot be determined, e.g. eschar, graft No No Yes Yes

Unspecified – Stage not specified No No No Yes

ICD-10-CMPressure Ulcer

• ICD-10-CM skin ulcer decision tree

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Non–Pressure Ulcer SeverityBreakdown of skin*

Fat layer exposed*

Necrosis of muscle*

Necrosis of bone*

Unspecified

*MS-DRGCCs

ICD-10-CMPressure Ulcer

• Skin ulcer sites

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Beyond Case Review Process Flow, Metrics, Projects

Process flow• Scope of concurrent review• Principal diagnosis selection• Secondary conditions to query/code• Query priorities• Query priorities• Complication code assignment• Pre-bill review• Query templates• Post-discharge query follow-up• Admission source• Discharge disposition

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• Metrics• Hospital-Specific Report (QualityNet Administrator)

46http://www.qualitynet.org – Hospital-Specific Report


• Metrics (cont.)• ARHQ software

47http://www.qualityindicators.ahrq.gov/Software/Default.aspx


• Projects• Definitions of terms• Admission/discharge disposition• Synergy with clinical performance

improvement• Documentation templates and/or

care delivery processes• Nutritional services• Skin assessments• Lab results reporting• Problem lists• Preop/anesthesia assessment• Procedure templates• Education

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Resources

• AHQR Toolkit• Designed to promote understanding and use of AHRQ Quality Indicators

(QI) to successfully improve quality and patient safety in hospitals• http://www.ahrq.gov/qual/qitoolkit/qifactsheet.htm

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Resources

• ICD-10-HAC List: http://tinyurl.com/cl3plfx

• AHRQ QI conversion to I-10: http://tinyurl.com/bbxk98x

• AHRQ: http://www.qualityindicators.ahrq.gov

• CMS VBPP/HRRP/HAC/Hospital Compare: http://tinyurl.com/a4zldst

• CMS HRRP: http://tinyurl.com/9kqtob2

• CMS HAC: http://tinyurl.com/az3nkuj

• CMS Hospital Compare: http://tinyurl.com/bxv8urg

• QualityNet: https://www.qualitynet.org

• CMS Inpatient Quality Reporting Program: http://tinyurl.com/akgs2l

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In Summary

• Clinical documentation improvement programs can be a significant contributor to how well your organization performs under various CMS claims-based value initiatives

VBPP1 5%

HRRP3%

HAC1%

Total5 5%FY 2015

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1.5%

VBPP1.75%

VBPP2%

3% 1%

HRRP3%

HAC1%

HRRP3%

HAC1%

5.5%

Total5.75%

Total6%

0 5

FY 2016

FY 2017

In SummaryThe Train Keeps Moving

• Three new claims-based measures on CMS Hospital Compare in 2013 – once posted for 1 year, CMS can elect to include in VBPP1

521http://www.cms.gov/apps/media/press/factsheet.asp?Counter=4422


In SummaryGet on Board!

• Find out how your organization is performing for claims-based metrics andperforming for claims based metrics and how metric performance is monitored

• Heighten awareness of how clinical documentation can contribute to improvement efforts

• Research metric data definitions,identify areas with documentationand coding vulnerability, roll up your sleeves, and have fun!

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Thank you. Questions?

In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section at the front of the workbook.

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Introduction Value-Based Purchasing Claims … Measurement Source Mortality AMI CHF PNA Claims The...

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