Screening Administrative Data To Assess the Accuracy Of Present-on-Admission Coding Michael Pine,...
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Screening Administrative Data
To Assess the Accuracy
Of Present-on-Admission Coding
Michael Pine, M.D., M.B.A.Michael Pine and Associates, Inc.
Chicago, Illinois773-643-1700
© 2008 Michael Pine and Associates, Inc.
Overview
Rationale for Development of POA Screens Developmental Database and Selection of Cases Description and Aggregate Performance of 12 Screens Evaluation of Coding By Individual Hospitals Computation of Composite Scores for Hospitals
© 2008 Michael Pine and Associates, Inc.
Rationale for Development of POA Screens
POA Code Identifies Hospital-Acquired ComplicationsImportant in Computing Rates of Adverse OutcomesImportant in Risk-Adjusting Performance Measures
Accurate Coding Requires Expertise and Teamwork Inaccurate Coding
Affects Assessments of Clinical QualityAffects Reimbursement
Chart Reviews to Detect Coding Errors Are Expensive Well-Designed Screens Can Detect Problems Efficiently
© 2008 Michael Pine and Associates, Inc.
Developmental Database
New York State SPARCS Data from 2003 through 2005 8,388,179 Discharges from 246 Hospitals Secondary Diagnosis Codes Have POA Modifiers
“1” = Present on Admission“2” = Hospital-Acquired“9” = Status on Admission Unknown
© 2008 Michael Pine and Associates, Inc.
Selection of Cases for Screening
High-Risk Conditions By Principal Diagnosis33 Categories (e.g., septicemia, respiratory failure)Mortality = 9.2%; 70% of Deaths; 22% of Discharges
Elective Admissions for Selected Surgical Procedures7 Procedures (e.g., hysterectomy, knee replacement)Principal Diagnosis Consistent with ProcedureOperation During First 2 Days of Hospitalization
Inpatient Childbirth By Diagnosis or Procedure Codes
© 2008 Michael Pine and Associates, Inc.
Diagnoses Almost Always Present on Admission
231 Diagnosis Groups (e.g., malignancy, osteoporosis) Analyzed for Each of the 3 Sets of Cases Screened Aggregate Data for Each Set:
Data Set # Codes % Inpatient % Unknown
High-Risk Conditions 5,506,043 1.13% 5.75%
Elective Surgery 588,874 0.63% 4.52%
Inpatient Childbirth 112,987 1.85% 8.93%
© 2008 Michael Pine and Associates, Inc.
Complications in High-Risk Conditions
Chronic Diagnoses with and without Acute Components21 Pairs (e.g., hernia with and without obstruction)Rates At Which Coded As Hospital-Acquired
Chronic without Acute: 1.06% of 1,612,079 DiagnosesChronic with Acute: 3.34% of 222,641 Diagnoses
Diagnoses Frequently Hospital-Acquired (e.g., anuria)3 Categories Based on Frequency Hospital-Acquired27 Diagnosis Groups in Category A; 59 in B; 54 in C
Category A - 63.5% of 172,472 Codes Hospital-Acquired Category B - 34.7% of 469,970 Codes Hospital-Acquired Category C - 24.8% of 772,049 Codes Hospital-Acquired
© 2008 Michael Pine and Associates, Inc.
Mortality with Hospital-Acquired Complications
Only for High-Risk Conditions Mortality Greater When Diagnosis Hospital-Acquired
3 Categories Based on Ratio of Mortality Rates66 Diagnosis Groups in Category A; 54 in B; 64 in CAggregate Data for Each Category:
Category # POA Dx % Dead # Hosp Dx % Dead Odds Ratio
A 348,860 12.6% 27,406 27.0% 2.57
B 747,172 15.3% 80,856 25.2% 1.87
C 1,335,879 21.2% 247,144 30.5% 1.64
© 2008 Michael Pine and Associates, Inc.
Complications in Elective Surgical Admissions
Diagnoses Frequently Hospital-Acquired Complications64 Diagnosis Groups (e.g., septicemia, shock)Of 138,655 Codes, 68.3% Hospital-Acquired
Chronic Diagnoses with and without Acute Components21 Pairs (e.g., asthma with and without exacerbation)Rates At Which Coded As Hospital-Acquired
Chronic without Acute: 0.39% of 187,453 DiagnosesChronic with Acute: 18.72% of 2,174 Diagnoses
© 2008 Michael Pine and Associates, Inc.
Risk-Adjusted Post-Op Lengths of Stay
High Rates of Prolonged LOS in Uncomplicated Cases Develop Predictive Equations for Routine Post-Op LOS
Compute Observed Minus Predicted Post-Op LOSFor All Live Discharges at Each Hospital
Create XmR Control Charts of OBS minus PRED LOSRemove Outliers with Prolonged Post-Op LOSRepeat Process Until No Further Outliers IdentifiedSet Upper Bound at Median Outlier Rate for All Hospitals
Repeat Process Using Only Uncomplicated CasesCompute Outlier Rates for Each HospitalIdentify Hospitals with Rates Greater Than Upper Bound
© 2008 Michael Pine and Associates, Inc.
Risk-Adjusted Post-Op Lengths of StayLive Discharges with and without Reported Complications
-10
0
10
20
30
40
50
60
1 31 61 91 121 151 181 211 241 271 301 331 361 391 421 451 481 511
Sequence Identifier
O
BS
LO
S m
inus
PR
ED
LO
S (d
ays)
Average 3 Std Dev Normal LOS Long LOS w Cpl Long LOS w/o Cpl
© 2008 Michael Pine and Associates, Inc.
Risk-Adjusted Post-Op Lengths of StayLive Discharges without Reported Complications
-10
0
10
20
30
40
50
60
1 38 82 129 180 225 270 310 354 398 448 491
Sequence Identifier
O
BS
LO
S m
inus
PR
ED
LO
S (d
ays)
Average 3 Std Dev Normal LOS Long LOS w/o Cpl
© 2008 Michael Pine and Associates, Inc.
Complications in Obstetrical Admissions
Diagnoses Usually Present on Admission7 Diagnosis Groups (e.g., multiple gestation)Of 448,242 Codes, 5.19% Hospital-Acquired
Fifth Digit Codes Incompatible with Inpatient Delivery737,125 Inpatient DeliveriesFifth Digit = “0” or “3” or “4” in 0.27%
Inpatient Post-Partum Complications74,669 Cases with Obstetrical Fifth Digit = “2”No Diagnosis Coded As Hospital-Acquired in 36.5%
© 2008 Michael Pine and Associates, Inc.
Initial Analyses of Hospital Coding
226 Hospitals Screened with One or More Measures 22 Hospitals Have More Than 10% Unknowns Diagnoses Almost Always Present on Admission
Less Than 2% of Diagnoses Hospital-Acquired
Data Set # Hospitals % Meeting Criterion
High-Risk Conditions 200 91.5%
Elective Surgery 123 89.4%
Inpatient Delivery 48 45.8%
© 2008 Michael Pine and Associates, Inc.
Hospital Coding for High-Risk Conditions
Chronic Diagnoses with Acute ComponentsHospital-Acquired Rate Greater Than 2% AND
Greater Than Twice Rate for Chronic CodesOf 145 Hospitals, 71.7% Met Criteria
Diagnoses Frequently Hospital-AcquiredHospital-Acquired Rate Greater Than 15% for
Category B Diagnoses AND Rate Monotonically Decreasing from Category A to Category C
Of 181 Hospitals, 83.4% Met Criteria
© 2008 Michael Pine and Associates, Inc.
Hospital Mortality Rates for High-Risk Conditions
Compute Predicted Mortality RatesIndirect Standardization within Each CategoryBased on Rates for Diagnoses Present on Admission
Odds Ratio of Observed to Predicted Mortality RatesGreater Than 1.60 for All Diagnoses ORGreater Than 1.30 for All Diagnoses AND Greater
Than 1.60 for Diagnoses in Categories A and B Of 184 Hospitals, 82.6% Met Criteria
© 2008 Michael Pine and Associates, Inc.
Hospital Coding for Elective Surgical Admissions
Diagnoses Frequently Hospital-Acquired ComplicationsHospital-Acquired Rate Greater Than 65%Of 175 Hospitals, 61.1% Met Criterion
Chronic Diagnoses with Acute ComponentsCompute 2 Standard Deviation Lower Bounds for
Hospital-Acquired RatesHospital-Acquired Rate Greater Than 12% AND Greater
Than Three Times Rate for Chronic Codes ORLower Bound Greater Than Twice Rate for Chronic Codes
Of 93 Hospitals, 96.8% Met Criteria
© 2008 Michael Pine and Associates, Inc.
Prolonged Risk-Adjusted Post-Op Length of Stay
Median Outlier Rate for All Live Discharges = 5.36% Outlier Rates for Uncomplicated Cases Less Than
Upper Bound:In 81.5% of 178 HospitalsIn 98.4% of 64 Reference HospitalsIn 71.9% of 114 Remaining Hospitals
© 2008 Michael Pine and Associates, Inc.
Hospital Coding for Obstetrical Admissions
Diagnoses Usually Present on AdmissionHospital-Acquired Rate Less Than 3%Of 134 Hospitals, 63.4% Met Criterion
Fifth Digit Codes Incompatible with Inpatient DeliveryLess Than 0.5% of Obstetrical Codes IncompatibleOf 134 Hospitals, 87.3% Met Criterion
Cases with Inpatient Post-Partum ComplicationsLess Than 20% without Hospital-Acquired DiagnosisOf 123 Hospitals, 41.5% Met Criterion
© 2008 Michael Pine and Associates, Inc.
Composite Hospital Scoring
Range of Points Assigned to Each MeasureRange from 1 to N with N = 4, 5, 8, or 10Score Only for 204 Hospitals with Adequate DataScore Measure Only When Volume Criteria Met
For Each Hospital, Compute:Total of Points Scored for Each MeasureMaximum and Minimum Possible Points
For Each Measure, Compute Average of Points Scored Obtain Final Adjusted Hospital Scores By Interpolation
© 2008 Michael Pine and Associates, Inc.
Final Adjusted Hospital Scores
Hospital Total Maximum Minimum Adjusted Score
Adjusted Score (%)
AVG 77.8 96 12 77.8 81.1%
A 96 96 12 96.0 100%
B 61 61 8 96.0 100%
C 66 96 12 66.0 68.8%
D 61 68 8 82.7 86.2%
E 54 57 7 88.8 92.5%
F 48 82 10 55.7 58.0%
© 2008 Michael Pine and Associates, Inc.
Screening and Improvement of POA Coding
POA Screening
Identification of Opportunities for
Improvement
Performance Evaluation
ProcessAnalysis
Interventionin Process
Plan forImprovement