CDQI RN: Data Quality ImprovementLocal ACDIS Chapter MeetingOctober 6, 2016Erin Nelson, CDQI RN, BSN, CCRNClinical Documentation Integrity ProgramSwedish Medical Center

Agenda

8. CDQI Focus Areas & Targeted Interventions (case examples removed from

disseminated version)

1. CMS Emphasizes Quality Over Quantity of Care

5. CDQI Impact Potential on Claims-Based Quality Metrics

4. CDQI Role Genesis

6. CDQI Role Key Objectives, Tactics & Strategies

3. Creation & Usage of Claims-Based Quality Metrics

9. Swedish Quality CDI Work Samples (removed from disseminated version)

2. Evolution of Pay-for-Performance Programs

7. CDI vs CDQI Role Differences

10. References

11. Q&A

• Episodes of Care with “Package Pricing”

• Bundled Payment Programs

• Per CMS:o Increases care coordination

o Reduces duplicationo Reduces unnecessary care

• Traditional Model

• DRG payment

• Separate payment for each service performed

Progression of CMS Healthcare Landscape

CMS is transitioning from volume of service to quality of serviceThe Changing Landscape

Fee-For-Service Pay-For-Performance

Alternative Payment Models

Previous State CMS: Current & Future State CMS:

• Fee-For-Service payments

• Fiscal penalties applied to all Medicare base DRG payments when there is poor quality performance

• Clinicians & Organizations are paid for beneficiary care over a period of time

• Volume of service and payment are not linked

Population Based Payment

Value

Based

Purchasing

HAC Reduction Program

Hospital

Readmissi

on Reduction Program

Core MeasuresMea

ningful

Use

“Rewarding hospitals for delivering services of higher quality and

higher value”

Medicare.gov

Evolution of Pay-For-Performance Programs

2010 Affordable Care Act

2002 2009

Claims-Based Quality Measures are included in Pay- for- Performance programs:• Value Based Purchasing (VBP)• Hospital Readmission Reduction Program

(HRRP) • HAC Reduction Program (HACRP).

CDQI Claims Based Quality Measures Explained

Inpatient Admission

Clinicians document throughout admission

Patient Discharged

Inpatient Coder Receives chart

for coding

Coding Completed

Inpatient coder finalizes coding claim & sends to

Medicare

Medicare Receives & Processes

Claim

Payment

Swedish receives

payment for hospitalization

Claim is used to determine

reimbursement

Quality Performanc

eClaim is used to

determine performance in certain quality

measures

Quality Performanc

e ScoresPerformance is measured over a rolling 3 year

period

Publically Reported

Performance

Quality performance

results released to Hospital Compare website

Financial Penalty

Poor performers incur a penalty

Start

END

Reimbursement

CMS Response to Complications of Care:

• Immediate: Will decline to pay for the increased cost of care associated with a HAC.

-and-• Delayed: Hand down

fiscal penalty for poor quality performance scores.

A CDI focused approach on quality metrics has proven to result in improvement in overall data quality. After success with PSI 15 focus, the CDQI role was created to focus specifically on quality metrics for analysis and improvement.

CDQI Role CatalystWhy CDQI?:

CDI vs CDQI Scope

CDI RN:Broad Documentation Integrity

CDQI RN:Quality Metrics

Focus

CDQI Intervention

Inpatient Admission

Clinicians document throughout admission

Patient Discharged

Inpatient Coder Receives chart

for coding

Coding Completed

Inpatient coder finalizes coding claim & sends to

Medicare

Medicare Receives & Processes

Claim

Payment

Swedish receives

payment for hospitalization

Claim is used to determine

reimbursement

Quality Performanc

eClaim is used to

determine performance in certain quality

measures

Quality Performanc

e ScoresPerformance is measured over a rolling 3 year

period

Publically Reported

Performance

Quality performance

results released to Hospital Compare website

Financial Penalty

Poor performers incur a penalty

Start

END

Reimbursement

Targeted Review for

Claims-Based Quality Metric

Integrity

AMIHFPneumoniaCOPDStrokeCABG

HRRP

Timeline: Claims-based Quality Measures

THA/TKA

30- DAY MORTALITY

30-DAY READMISSION

COMPLICATIONS

AMIHFPneumoniaTHA/TKACOPDCABGStrokeLikely future HRRP addition

VBPVBP

VBP

VBP

HRRP

HRRP

HRRPHRRP

HRRP

2014

2019

2010

2017

2015

2011

2012

2013

2018

2020

2016

2007

2009

2008

METRIC

PSI 90

ACA passed

Metric Added to Pay-For-Performance Program

Metric Dry Run

Metric Added to IQR

VBP & HACRP

Likely future VBP addition

VBP & HRRP Starts

HACRP Starts

LEGEND

PROGRAM CLAIMS -BASED METRIC FY 2017 BASELINE PERIOD

FY 2017 PERFORMANCE PERIOD

Value Based Purchasing

30-Day Mortality:• AMI• Heart Failure• Pneumonia

Oct. 1, 2010 – June 30, 2012

Oct. 1, 2013 - June 30, 2015

Value Based Purchasing

PSI 90 Oct. 1, 2010 – June 30, 2012

Oct. 1, 2013 - June 30, 2015

HAC Reduction Program

PSI 90 N/A July 1, 2013 - June 30, 2015

Hospital Readmissions Reduction Program

30-Day Readmission• AMI• HF• Pneumonia• THA/TKA• COPD• CABG

N/A July 1, 2012 - June 30, 2015

One Year Lingers in Pay-for-Performance Scoring

ExamplePoor HRRP performance in 2015 impacts scores for 4

fiscal years:FY2017 (7/1/12-6/30/2015)FY2018 (7/1/13-6/30/2016)FY2019 (7/1/14-6/30/2017)FY2010 (7/1/15-6/30/2018)

Measures• Communication with nurses• Communication with doctors• Responsiveness of hospital

staff• Pain Management• Communication about

medicines• Cleanliness & quietness• Discharge information• Overall rating of hospital

MeasuresOutcomes:• 30- day Mortality: AMI, HF, PNA

Process: • AMI 7a• IMM-2• PC-01

Measures• AHRQ PSI-90 Composite• CAUTI• CLABSI• C.diff infection• MRSA• SSI:

o Colon surgeryo Abdominal Hysterectomy

Value Based Purchasing FY 2017

Patient Experience of

Care 25%

Safety 20%

Clinical Care30%

Efficiency & Cost Reduction

25%

Medicare Spending Per Beneficiary

ACA established. Program kicked-off in 2013 POOR PERFORMER

S

Maximum penalty 2% of all Medicare base DRG payments

HIGH ACHIEVERS

Incentive payments Up to 2% of all Medicare base DRG paymentsCDI IMPACT POTENTIAL

Process 5% +

Outcomes 25%

VBP Financial ImplicationsFiscal Year Percent

Reduction2016 1.75

2017 2.0

Succeeding Years 2.0

• Eligibility requirements• 2016: must meet threshold in 2/4

domains• 2017: must meet threshold in 3/4

domains

• All eligible hospitals: Medicare payments are reduced by set percentage of base MS-DRG payment

• Only CMS program in which a hospital can make money

• Hospital earns bonus or penalty based on: • Achievement points• Improvement points• Consistency points

FY 2016 Net Percentage

ChangeMaximum Penalty - 1.75

Average Change Between -0.4 to + 0.4

Maximum Bonus Slightly more than + 3

VBP CDI Impact Potential

Patient Experience of Care• Press Ganey survey

Clinical Care Process Measures

Hospital Acquired Infections• SSI- Colon surgery, Abdominal

Hysterectomy• CAUTI• CLABSI• MRSA• C. diff Infection

NOT Claims Based

30-Day Mortality• AMI• HF• PNA

AHRQ PSI-90 Composite

PC-01• Elective C-section at 37-39 weeks

gestation

Medicare Spending Per Beneficiary• HCC Risk Adjustment• MS-DRG assignment

Claims Based VS

DRA HAC Measure

Reporting

HAC Reduction Program

2005 Deficit Reduction Act

(DRA)14 HACs in 11

Categories Immediate

2010 Affordable Care Act (ACA) PSI 90 Composite Delayed

Creation Measures $ Penalty

Hospital-Acquired Conditions: 2 CMS Programs

Hospital-Acquired Condition (HAC) Reduction Program

PSI 90 COMPOSITE

DOMAIN 1

CAUTI

SSI

CLABSINHSN Data

Not Claims-Based

Claims Data

DOMAIN 2

• Established by ACA• Started in 2015

Bottom 25% of

performing hospitals incur 1%

penalty on all

Medicare base DRG payments

HAC Reduction Program

TOTAL HAC SCORE

CDI IMPACT

POTENTIAL

FY 2016: 15% of Total HAC

Score

FY 2016: 85% of Total HAC

Score

Provides a perspective on patient safety

Complication or adverse event

Developed by AHRQ• 27 PSIs• 11 PSIs within the AHRQ PSI 90 composite• 8 PSIs recognized by CMS in the PSI 90

composite. These 8 are NQF endorsed

Patient Safety Indicator (PSI) 90 Composite

PSI 90 Composite

PSI 90 is a Composite of Indicators used in the HAC Reduction Program & Value Based Purchasing

Key Takeaway

PSI 90 Version 6.0PSI Metric

Modified Metric Added

PSI 3- Pressure Ulcer RatePSI 6- Iatrogenic Pneumothorax RatePSI 8- In-Hospital Fall with Hip Fracture Rate XPSI 9- Perioperative Hemorrhage or Hematoma Rate

X

PSI 10- Postoperative Acute Kidney Injury Rate XPSI 11 – Postoperative Respiratory Failure Rate XPSI 12- Perioperative PE or DVT Rate XPSI 13- Postoperative Sepsis RatePSI 14- Postoperative Wound Dehiscence RatePSI 15- Unrecognized Abdominopelvic Accidental Puncture/Laceration Rate

X

PSI 90 FY2016 Changes- v6.0

• In depth info on FY2016 PSI 90 changes: http://qualityindicators.ahrq.gov/News/PSI90_Factsheet_FAQ.pdf

Spotlighted Changes

Description

There was a name change Changed from “Patient Safety of Selected Indicators Composite” to “Patient Safety and Adverse Events Composite” to capture the concept of patient harm resulting from the event

The number of component indicators increased from 8 to 10

PSI 7- CLABSI was removedPSI 9,10 & 11 were added.

Changes were made to PSI 8, 12 and 15. PSI 8-1. Now includes all hip fractures from inpatient falls, not just those that occur

postoperativelyPSI 12- 2. Isolated calf vein DVT was removed as a numerator specification. 3. Patients with any diagnosis of acute brain and/or spinal injury were removed from the

denominator specifications. PSI 12 events may be less preventable due to safety concerns with pharmacological prophylaxis

PSI 15- 4. Refined to focus on most serious intraoperative injuries due to an acc punc/lac.

Denominator is now limited to abd/pelvic sx. 5. Name change to “Unrecognized Abdominopelvic Accidental Puncture/Laceration Rate”

*** CMS has not adopted the new changes yet, CMS is still using v5.0

ACA established. Program kicked-off in 2013.

• Discharged AMA• Planned Readmissions• Exclusions variable based on Population. For example,

THA/TKA unplanned readmission exclusions:

Hospital Readmission Reduction Program (HRRP)

Condition Specific• AMI• HF• Pneumonia• COPD

Procedure Specific• THA/TKA• CABG

Planned Readmission AlgorithmIdentifies readmissions that are excluded

Exclusion Criteria

Inclusion Criteria• Medicare FFS Part A & B• Enrolled for at least 12

months • Age 65+

Metric Populations• All-Cause Unplanned 30-

day Readmission

POOR PERFORMER

S

Maximum Penalty

3% penalty to all

Medicare base DRG payments

Outcome Metric

• More than two THA/TKA procedure codes during index

• Transfers to another acute care facility

• POA fracture

• Concurrent revision or resurfacing procedure

• PDX- Mechanical complication

• PDX- Malignant neoplasm• Removal of implanted

devices/prostheses

PROGRAM CLAIMS -BASED METRICS CLAIMS-BASED METRICS –PROGRAM SCORE IMPACT FY 2017

MAX $$$ PROGRAM PENALTY

Value Based Purchasing

30-Day Mortality:• AMI• Heart Failure• Pneumonia• Likely additions: COPD,

StrokePSI 90THA/TKA Complications

Approximately 35%*** Outcomes 25% + Safety Measures 20% (includes NHSN metrics)

2%

HAC Reduction Program

PSI 90 15% 1%

Hospital Readmissions Reduction Program

30-Day Readmission• AMI• HF• Pneumonia• THA/TKA• COPD• CABG

100% 3%

SUMMARYClaims-Based Measures, Program Penalties, & CDI Impact Potential

CDI IMPACT POTENTIAL

Inpatient coder codes chart

Reimbursement & Quality Data

Claim sent to insurance company

CDI & CDQI Scope & Focus AreasScope of CDI & CDQI Process

• Incorrect code assignment• Over/underreporting

of certain diagnoses

• Denials• RAC audit

• Overpayment• Underpayment• CMI inaccurate• Inaccurate Quality

Data

Role Focus:

MD documents

• Missing or conflicting documentation• Failure to rule out a

diagnosis

CDI

CDQ

I

• Incorrect PDX assignment• Missing or incorrect

code assignment• POA status incorrect• Over/underreporting

of complications

• Inaccurate claims data

Inaccurate Quality Data• O:E • PSI• Mortality• Readmissions

• Missing exclusion criteria• Missing

documentation of risk factors• Missing POA status• Confusing

documentation around potential complications

CDQI Strategy, Tactics & ObjectivesBreak down process and communication barriers to allow for a consistent coding experience in order to ensure data integrity, driving major decision making across the organization.

Core Objective:

• Improve Swedish Quality Outcomes

• Build accuracy & trust in data

• Identify abnormal trends

Why?• Envision and execute process changes to quality metrics documentation and coding

• Efficient communication channel between providers & coding staff

• Tell a story about data trends enabling medical professionals to take action

What?• Build process and tools

to enable coders to accurately code charts

• Educate providers around key components and pitfalls of data quality process

• Provide documentation feedback to providers specific to quality metrics

How?

PSI 90

Mortality

ReadmissionsMisc.

Consultation

• Coding department

• CDI department• Quality

department• Physician

champions

• Coding department

• CDI department• Quality

department• Physician

champions

• Coding department

• CDI department• Quality

department• Physician

champions

CDQI Focus Areas

Erin Nelson CDQI RN

• Establish clear review process for readmissions

• Become subject matter expert• Identify common documentation and

coding pitfalls and collaborate on solutions

• Establish clear review process for mortalities

• Become subject matter expert• Identify common documentation and

coding pitfalls and collaborate on solutions

• Establish clear process for review• Become subject matter expert• Identify common documentation and

coding pitfalls and collaborate on solutions

Objectives Key Players

• Quality Department

• Various departments

• Consistent Resource, Presence, & Liaison with Quality Department

Patient Safety Indicators Current State

Barriers

Desired Future StateEstablished PSI Process Flow:

1. Identification: • PSI 15 & 12- Stop billed•All other NQF endorsed PSI 90- Jvion & Premier

2. Case Review & Provider query3. Coding Recommendation4. Track Impact & Trends5. Documentation solutions:

Stop-Bill on all PSI cases pending CDQI review

1. Provider PSI Query Response2. CMS only recognizes top 25 codes

1. MD Champions, Escalation Process2. Re-sequence exclusions in top 25

codes.

PSI 90

B. CDI departmental education:• Departmental meeting

presentations• Reference notebook• Individual discussions

A.CDI Physician coordinator driven MD education• Pressure Ulcer SmartPhrase • DVT drop down menu • DVT/PE Documentation

Presentation

Mitigation Strategies

30-Day MortalityCurrent State

Barriers

Desired Future State• Retrospective mortality review• Reviewing CHF mortalities as concurrently as possible

1. Identification: 2. See Case Review process flow (on future slide)3. Track Impact & Trends

a. Excel spreadsheet shared with colleague in Quality Department

4. Documentation Solutions:

Stop-Bill on all CMS Condition-specific and Procedure-specific

mortalities (PENDING)

Risk adjustment review infused in concurrent CDI review

1. Labor intensive2. Multiple provider groups report diagnoses 3. Premier reporting system does not refresh corrected cases4. CMS only recognizes top 25 codes

1. Designated accountable providers MD

2. Education: O/E optimization.3. Template work: make risk variables

easy to capture.4. Re-sequence risk variables to top 25

codes.

Mortality

B. CDI MD Coordinator : • Template work• SmartPhrases• Drop down menus

A. CDQI-driven Provider education • Understanding the metric• Documentation for O/E

optimization

Mitigation Strategies

30-Day Readmissions Current State

Barriers

Desired Future StateRetrospective readmission review

1. Identification: a. Premier b. Vantage

2. CDQI case review: a. Low hanging fruit: fix cases with wrong PDX, request added

codes for documented risk variablesb. Identify mixed documentation of risk variables

3. Track Impact & Trendsa. Consultative reviewsb. Ongoing readmission reviews

4. Feedback to MD groupa. Presentationsb. Individual discussions

Concurrent Readmission Capture

Risk adjustment review infused in concurrent CDI

review

1. Labor intensive2. Multiple provider groups report the diagnosis 3. Premier reporting system does not “refresh” to reflect changes 4. CMS only recognizes top 25 codes

1. Designated accountable providers MD

2. Education: O/E optimization.3. Template work: make risk variables

easy to capture.4. Re-sequence risk variables to top 25

codes.

Mitigation Strategies

Readmissions

How CMS Determines the “Expected” Outcome

CMS Expected Outcome Methodology

Observed Outcome

Expected Outcome =

SexCMS-derived Hierarchical

Logistic Regression

Model

Expected Outcome =

Condition-Specific

POPULATION=

Performance Scoring Criteria

Comorbid disease

Patient Frailty

Age

Predicted Outcome

Expected Outcome*CMS speak for O/E

Observed deaths

Expected deaths

30-Day Readmission & 30-Day Mortality- CDQI Impact Potential

Hospital Wide

=Higher than 1

The Patient (CDI) Level

1 (The deceased)

Relative Expected Mortality (REM) =

Comorbidity 1

Comorbidity 2

Comorbidity 3

(Missing)

Observed Outcome

Expected Outcome

Specified Population

Risk Factor(Missing) Risk Factor

(Missing) Risk Factor (Missing)

Risk Factor (Missing)

Incorrect PDX

Risk Factor (missing)

Risk Factor (Missing)Incorrect

PDX

Risk Factor (missing)

Principal Diagnosis Verification

Identify Missing Risk Variables

CDQI InterventionEliminates incorrect observed cases

Accurately reflect expected outcome

CDQI Impact

Accurate O/E ratio

Aggregate Effect

Coefficients: • Age• Comorbid disease • Indicators of Patient Frailty

Source:• Inpatient• Outpatient• Physician Medicare administrative claims

data

12 month look back + index admission

CMS-derived Hierarchical Logistic Regression Model

CMS Risk Adjustment Example: AMI 30-Day Mortality Measure

Example: AMI 30-Day MortalityRisk Adjustment Variables

Risk Adjustment Drill Down

DRILL DOWN: Renal Failure (CC 131)

CC= Condition CategoryGrouping of similar diagnosis codes into diseases that are

related clinically and with respect to cost

The presence of a code from a CMS-identified CC will incrementally increase the risk of the expected outcome

Example: AMI 30-Day MortalityRisk Adjustment Variables

ICD-9 Code

Code Description

CC CC Description

Chronic Kidney Disease, Stage II is Documented

Code is contained within CC 131

CC 131 is an identified CC for the AMI 30-Day

Mortality Metric

Increase in Expected Mortality

Improvement in O/E

Case-Level Review Process

• Reviews documentation within 2 business days.

• Identifies coding variances

• Identifies potential missing risk factor documentation & discusses with MD

•Notifies coding of potential coding variances

•Notifies coding of MD chart note addendums

• Tracks occurrence of requested coding changes

• Updates spreadsheet

Expectations:

•Manages Stop-Bill work queue.

•Notifies clinician

CQD

ICl

inic

ian • Reviews documentation

within 2 business days.

• Ensures PDX diagnosis appropriate

• Chart note addendums to:

• clarify inappropriate PDX diagnosis • add missing risk factor documentation.

•MD to MD communication

• Follows spreadsheet.

• Receives notification of patient mortality by CDQI RN.

Adjudication Flow

CMS Mortality Chart ReviewChart Addendum

and Coding Recommendations

Loop Closure & Coding

Reconciliation

ReferencesAHRQPSI Resourceshttp://www.qualityindicators.ahrq.gov/modules/psi_resources.aspx

CMSValue Based Programshttps://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/Value-Based-Programs.html

Quality NetClaims Based Measureshttps://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier2&cid=1228763452133

Questions?Erin.Nelson@Swedish.org