The Increasing Importance of - ACDIS...MS‐DRG 872/871: Septicemia or severe sepsis w/oMV > 96...

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Katy Good, RN, BSN, CCDS, CCSCDI Program Coordinator

Flagstaff Medical Center, Flagstaff, ArizonaLaura Saldivar, CCS, CPC, COC

DRG AuditorConnolly IHT, Gilbert, AZ

SOI/ROM: The Increasing Importance of Risk‐Adjusted Metrics

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Learning Objectives

• At the completion of this educational activity, the learner will be able to:

– Increase understanding of APR‐DRGs and how SOI/ROM are stratified in this system

– Recognize how SOI/ROM impact revenue and risk‐adjusted metrics in the current healthcare market

– Visualize how to use APR‐DRGs to improve risk‐adjusted metrics

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Background


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Background

• CDI was initially formulated around the DRG system in which specific and accurate documentation ensures proper reimbursement; guaranteeing appropriate payment for services rendered

• Typically directed at MS‐DRGs (CMS)

• Revenue focused

• Limited scope

• CC/MCC capture

CDI: A DRG‐focused initiative

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Background

• The industry is rapidly changing to OUTCOME‐BASED healthcare

• Opportunity to expand CDI into a truly comprehensive, all‐payer format

– Accurate reimbursement

– Accurate quality scores

– Accurate hospital profiling

– Accurate documentation

• The evolving healthcare industry requires utilizing systems to measure severity of illness beyond MS‐DRGs

CDI: A DRG‐focused initiative

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MS‐DRGs vs. APR‐DRGs


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• “… our primary focus of updates to the Medicare DRG classification system is on changes relating to the Medicare population ... Our mission in maintaining the Medicare DRGs is to serve the Medicare population ...”

Federal Register/Vol. 69 No. 96/May 2004

Medicare DRGs

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• Effective in 2007

• Three‐tiered

• 745 MS‐DRGs

• Focused on resource intensity

• Allows minimal assessment of SOI

Medicare DRGs

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• The changing healthcare industry demanded a tool that went beyond resource intensity to evaluate mortality rates and quality of care

• All Patient Refined DRGs were developed by 3M to meet this need

– Intended for all‐payer/all‐patient

– Allows for improved evaluation of SOI/ROM

– Increased stratification by classifying acuity on a scale of 1–4

APR‐DRGs


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• 315 base APR‐DRGs

• Subdivided into 4 SOI subclasses and 4 ROM subclasses

• Two “error” APR‐DRGs (955, 956)

• Results on 1,262 possible APR‐DRG assignments

– Compared to 752 MS‐DRGs

Structure

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• Significant pediatric and adult problems have separate APR‐DRGs depending on patient population

– Neonates

– Pediatric conditions

– Eating disorders

– Drug/alcohol

– Behavioral health

– Maternity

Elements

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• Severity of illness: Extent of physiologic decompensation or loss of organ system function that the patient experiences

• Risk of mortality: Likelihood that the patient will die on THIS admission

• Numeric qualifier assigned separately– 1: Minor– 2: Moderate– 3: Major– 4: Severe

• Patient age is a factor in assessing severity

Elements


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• Overall DRG SOI/ROM are aggregated based on the SOI/ROM of individual diseases, procedures performed, age of patient, and the interactions between the patient’s disease processes

• SOI/ROM for specific illnesses are not stagnant

Identical code: 3 different SOI assignments

Elements

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APR‐DRG Impact

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APR‐DRG Impact

• Medicaid in 24 states is using APR‐DRGs for payment

• 2 additional states have announced that they will transition to APR‐DRGs in 2016/2017 for Medicaid reimbursement

– Alabama (October 2016)

– Wisconsin (January 2017)

• 11 commercial payers and non‐Medicaid agencies are using APR‐DRGs for payment

APR‐DRGs and revenue


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APR‐DRG Impact

Organizations in 30 states use APR‐DRG methodology for payment and/or quality reporting

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APR‐DRG Impact

• Similar to MS‐DRGs

– DRG relative weight (RW)

• Base DRG

• Severity adjustment

– Provider APR‐base rate

RW X base rate = DRG reimbursement

APR‐DRGs and revenue

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Example: Severity Adjustment

MS‐DRG 235/236: Coronary Bypass W/O Cardiac Cath

APR‐DRG 166: Coronary Bypass W/O Cath

Pdx Coronary Artery Disease

Ppx CABG‐single vessel

Hyperlipidemia Hyperlipidemia Hyperlipidemia Hyperlipidemia

DM I with hyperglycemia



BMI 46 BMI 46

Obesity Hypoventilation

Obesity Hypoventilation

Post‐op HF

ARF with Hypoxia

SOI/ROM 1/1 2/1 3/1 4/4

RW 2.6441 3.0517 4.0194 7.0219


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Example: Financial Impact

$16,298 $18,811 $24,776 $43,284

MS‐DRG 236 MS‐DRG 235

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APR‐DRG Impact

• In the future (if not already) we can expect to see APR‐DRG denials in the same way we currently see MS‐DRG denials

– Additional variables

– New targets

– Increasing complexity

APR‐DRGs and denials

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APR‐DRG Impact

Several agencies, consulting companies, data companies, etc. that report quality data use APR‐DRGs to calculate expected rates and report on quality of care

APR‐DRGs and quality

• Deaths

• Complications

• Length of stay

• Readmissions

• U.S. News and World Report

• AHRQ

• Healthgrades.com

• Premier, Inc.

• JCAHO


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APR‐DRG Impact

• Additional quality reporting

– Many methodologies are used

– Not all are using APR‐based methodology

– However, APR‐DRGs are a starting point that is readily available to most hospitals

• Overlap

APR‐DRGs and quality

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APR‐DRG Strategies

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• Two pieces to risk‐adjusted metrics

– Expected

– Observed

• APR‐DRG focused reviews can improve our EXPECTED rate by increasing patients’ aggregated severity of illness

Leveraging CDI to improve risk‐adjusted metrics


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• Comprehensive documentation and coding capture

• Beyond MS‐DRG optimization

• Beyond CC/MCC capture

• Capture of ALL diagnoses that may impact SOI/ROM

Strategies

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• COPD, stable

• Diabetes mellitus with hypoglycemia

• Hyperkalemia

• Cardiomyopathy

• Hypotension

• Anemia in chronic disease

• Dysphagia

• Parkinson’s disease

• Hypocalcemia

• Sick sinus syndrome

• Fatty liver

• Anemia in CKD

• Fluid overload

• Seizures/convulsions

• Not limited to CC/MCCs for granularity

• NCCs can impact SOI/ROM

• Thrombocytopenia

• Hypoglycemia

• Hypomagnesemia

• Alcoholic cirrhosis w/o ascites

• Alcoholic hepatitis w/o ascites

• Alcoholic liver failure w/o coma

• Pressure ulcers (stage 1+)

• Alzheimer's

• Dementia

• Opioid dependence

• Heart failure, unspecified

• Unspecified A‐fib

• Dehydration

• Anorexia

Beyond CC/MCCs

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• Especially important in relatively low‐severity cases

• CC/MCCs may not be present

– Often thought of as “zero opportunity”

• Low relative weights

• Scheduled surgeries

• Short length of stay

Beyond CC/MCCs


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APR‐DRG Impact

• Not all impactful NCCs are the same

– Most are low (2/1, 2/2)

• Some are high‐value

– Hypotension

– Pressure ulcers

– Seizures

• SOI/ROM can vary within a single code

Beyond CC/MCCs

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MS‐DRG 690: Kidney and urinary tract infections

APR‐DRG 463: Kidney and urinary tract infections

Pdx Urinary tract infection, unspecified

Ppx None

Sdx Pressure ulcer of lower back, stage 1

SOI/ROM 1/1 2/2

RW 0.3999 0.5233

NCC examples

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MS‐DRG 470: Major joint replacement or reattachment of lower extremity w/o MCC

APR‐DRG 302: Knee joint replacement

Pdx Degenerative joint disease

Ppx Total knee replacement

Sdx Hypotension

SOI/ROM 1/1 2/2

RW 1.4391 1.6326

NCC examples


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• Z‐codes (V‐codes in I‐9): Factors influencing health status and contact with health services

• Z‐codes can impact SOI/ROM

– Dependence on supplemental 02

– Transplant status

– Awaiting transplant status

– Ostomy codes

Z‐codes

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MS‐DRG 470: Major joint replacement or reattachment of lower extremity w/o MCC

APR‐DRG 302: Knee joint replacement

Pdx Degenerative joint disease

Ppx Total knee replacement

Sdx COPD, unspecified COPD, unspecified

Sdx Dependence on supplemental 02

SOI/ROM 1/1 2/1

RW 1.4391 1.6326

Example: Z‐codes (status codes)Z99.81 Dependence on supplemental oxygen

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MS‐DRG 690: Kidney and urinary tract infections

APR‐DRG 463: Kidney and urinary tract infections

Pdx Urinary tract infection, unspecified

Ppx None

Sdx Hepatic failure Hepatic failure

Awaiting organ transplant

SOI/ROM 1/1 2/2

RW 0.3999 0.5233

Example: Z‐codes (status codes)Z76.82 Awaiting organ transplant


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• Some non‐surgical procedures may impact SOI/ROM

– Mechanical ventilation

– TPN

– Hemodialysis

Non‐surgical procedures

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MS‐DRG 189 Pulm edema & resp failure 208 Resp dx with mech vent < 96 hrs

APR‐DRG 139: Other pneumonia

Pdx Pneumonia, unspecified

Sdx Acute on chronic respiratory failure Acute on chronic respiratory failure

Ppx Mechanical vent 24–96 hours

SOI/ROM 3/2 4/3

RW 0.9394 1.8747

Example: Non‐surgical procedures5A1945Z Respiratory ventilation, 24–96 hours

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Metric Impact


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Metric Impact

• Observed versus expected rate

• Ratio based off all patients

– Even the low‐severity, simple ones!!!

• Rate > 1 is unfavorable

• May indicate SOI/ROM is not being reflected accurately in the coded data

Risk‐adjusted metrics

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Example: Mortalities

• Top priority identified at Flagstaff Medical Center

– Demanded intense focus

• Concurrent CDI review of expanding patient population (beyond Medicare)

• Additional retrospective review of mortalities

Mortalities: O/E ratio

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• Collaboration between coding and CDI to ensure accurate assignment of SOI/ROM

– Billing hold on all patients with D/C status of 20

– Coded in draft and sent to CDI for review

– Post‐discharge

– Send queries (if indicated) and feedback provided

– Build electronic worklist/database

Mortalities: O/E ratio


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MS‐DRG 872/871: Septicemia or severe sepsis w/o MV > 96 hours w/o MCC

APR‐DRG 720: Septicemia & disseminated infections

Pdx Sepsis, unspecified

UTI, unspecified UTI, unspecified UTI, unspecified UTI, unspecified

COPD, stable COPD, stable COPD, stable

Alcohol dep. with withdrawal

Alcohol dep. with withdrawal

Alcohol dep.with withdrawal

Aspiration pneumonia

Aspiration pneumonia

Hypoxic resp. failure

SOI/ROM 1/1 2/2 3/3 4/4

RW 0.5296 0.7147 1.2250 2.8127

Mortality adjustment

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Outcomes: O/E

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

2

2010 2011 2012 2013 2014 2015

O:E

baseline

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0.20%

0.70%

1.20%

1.70%

2.20%

2.70%

3.20%

3.70%

4.20%

Jun‐11

Oct‐11

Feb‐12

Jun‐12

Oct‐12

Feb‐13

Jun‐13

Oct‐13

Feb‐14

Jun‐14

Oct‐14

Feb‐15

Jun‐15

Expected

Outcomes: Expected rate


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Metric Impact

0

0.2

0.4

0.6

0.8

1

1.2

2009 2010 2011 2012 2013 2014 2015

LOS

baseline

Linear (LOS)

Length of stay O:E

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Readmissions O:E

Metric Impact

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

2012 2013 2014 2015

Series 1

Linear (Series 1)

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Metric Impact

0

0.2

0.4

0.6

0.8

1

1.2

2011 2012 2013 2014 2015

O:E

Benchmark

Complications: Hip replacement


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Implementing a Risk‐Adjusted Model

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• Quality– Identify problem areas– Risk‐adjusted metrics

• Complications• Mortalities

• Utilization review– Identify problem areas– Length of stay

• Coding/billing– Ensure a comprehensive coding summary– APR denials– Retrospective APR‐DRG reviews

Engage

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• Management/leadership– Explain how CDI can be leveraged for metric impact– Explain financial benefit of extended reviews– If possible, use this to gain support for increased resources

• Additional FTEs

• CDI– Complete capture of CC/MCCs– NCC awareness– Review ENTIRE record

• Medication list.• Wounds!

• Coding– Complete capture of CC/MCCs– NCC awareness

Educate


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• Maximize existing reviews

– Review beyond CC/MCCs

– Target NCCs that carry weight

• Consider expanding to other (APR) payers

• Consider expanding to all‐payer reviews

Concurrent reviews

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Conclusion

Understand risk adjustment.– Share information with others!!

Know your data!– Where are the problem areas?

Engage with other departments.– Educate coding

• Impact

– Quality staff

Recognize that there are many ways to risk‐adjust.– This is a STARTING point

Considerations

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Sources

• https://www.azahcccs.gov/commercial/ProviderBilling/rates/APRDRG.aspx

• http://solutions.3m.com/wps/portal/3M/en_US/Health‐Information‐Systems/HIS/Products‐and‐Services/Products‐List‐A‐Z/APR‐DRG‐Software

• http://www.healthgrades.com/quality/methodology‐mortality‐and‐complications‐outcomes


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Thank you. Questions?

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The Increasing Importance of - ACDIS...MS‐DRG 872/871: Septicemia or severe sepsis w/oMV > 96...

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