gaining physician buy-in to cdi using quality data · gaining physician buy-in to cdi using quality...
TRANSCRIPT
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7th AnnualAssociation for Clinical Documentation
Improvement SpecialistsConference
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Gaining Physician Buy-In to CDI Using Quality Data
Sylvia Hoffman, RN, CCDS, C-CDI, CDIP
President/CEO
Sylvia Hoffman Consulting
Tampa, Fla.
Timothy Brundage, MD, CCDS
Medical Director
Brundage Medical Group, LLC
Redington Beach, Fla.
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Learning Objectives
• At the completion of this educational activity, the learner will be able to:– Identify the need for effective physician
documentation
– Describe the relationship of physician documentation to pay for performance, quality metrics, ROM and SOI scores
– Use retrospective physician report cards as tools for educating physicians
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The business of medicine has radically changed, but many physicians are still
struggling with the message.
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Inform Your Physicians That Statistics are Being Collected
• Length of stay (LOS)• Case-mix index (CMI)• Resource utilization• Cost per patient • Patient satisfaction• Readmission rates• Pay for performance• Quality of care• Severity of illness (SOI) • Risk of mortality (ROM)
*Statistics for previous 2 years influence current data and profiles!
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Who Is Looking at Documentation?
• Third-party payers
• Fiscal intermediaries (FI)
• Office of Inspector General (OIG)
• State agencies
• QIOs
• RACs, MACs, MICs, etc.
• Healthcare facilities
• Beneficiaries/patients
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Why Should Physicians Care?
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Physician Profiling
• Profiling websites publish data on the Internet
• Profiles are used for both commercial and public use
• Public utilize profiles to select provider
• Future reimbursement methods will likely incorporate profiles in the formula
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Profiling and Risk-Adjusted Data
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HealthGrades.com
Example of website
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UCompareHealthCare.com
• Dr. Hoffman MD
• Obstetrician/Gynecologist — Tampa, Fla.
• 5 Excellent
• Contact Dr. Hoffman — based on 1 review
• Dr. Mitchel Hoffman specializes in obstetrics & gynecology, gynecology/oncology in Tampa, Florida. Details of Dr. Hoffman's 32 years experience as an MD, his hospital affiliation, and education at University of South Florida are available.
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RateMDs.com
Dr. Hoffman Rating 4 out of 5 (5 is best), based on 4 reviews
Location: Tampa, Fla.
Gender: Male
Specialty: Oncologist/Hematologist
Website: ----------------------
Practice: University of South Florida College of Medicine
Hospital: Tampa General Hospital
Phone: 813--------------
Med. School: University of South Florida College of Medicine
Grad. Year: 1981
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Insurance Provider Profiles
GAO report says physician profiling could help control Medicare costs. Publish date: July 01, 2007.
PurchaserNo. of Plan Members
Type of Physician Practice Profiled
No. of Physicians
Profiled
Aetna 500,000 Group 15,000
Blue Cross Blue Shield of Texas 60,000 Group and Individual 26,000
Greater Rochester Independent Practice Association
120,000 Individual 640
Health Insurance BC (British Columbia, Canada) 4.1 million Individual 8,000
HealthPartners 650,000 Group 27,000
Hotel Employees and Restaurant Employees International Union Welfare Fund
130,000 Group and Individual 2,000
Massachusetts Group Insurance Commission 268,000 Individual 19,000
Minnesota Advantage Provider Groups Health Plan 115,000 Group 50
PacifiCare Health Systems 1.5 million Group 14,000
United Healthcare 10.6 million Group and Individual 80,000
Healthcare purchasers’ physician profiling programs examined by GAO
Source: GAO Report: “Focus on Physician Practice Pattern Can Lead to Greater Program Efficiency.” April 2007
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Other Factors of Importance
Severity of illness Risk of mortality
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LOS ExampleCervical Spinal Fusion
MS-DRGtype
Number of cases
ActualLOS
GMLOS Variance Hospital costs Medicare Reimbursement rate
DRG 471(with major
comorbidity)
2313%
11.48 7.0 +4.48 $45,794$35,721
$-10,253/case
DRG 472(with
comorbidity)
4928%
4.27 2.8 +1.47 $25,989$21,118
$-4,871/case
DRG 473(w/o
comorbidity)
10359%
2.49 1.6 +.89 $20,468$15,496
$-4,972/case
Reflects poorly on physician LOS statistics
HCPro CDI Boot Camp Course Materials, module 15, slide 19
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Diagnosis DRG LOS GMLOS Variance
Septicemia and severe sepsis w MV 96+hours
871 176 days 22.9 days +153 days
Septicemia and severe sepsis w MV 96+hours w MCC
870 128 days 29.6 days +98 days
Resp. infection w MCC 177 88 days 22.7 days +65 days
Resp. system diagnosis w MV 96+hours
207 85 days 32 days +53 days
Kidney and UTI w MCC 689 85 days 21.8 days +63 days
Simple pneumonia w MCC 193 70 days 20.1 days +50 days
COPD w MCC 190 66 days 19.8 days +46 days
Simple pneumonia w CC 194 66 days 18.4 days +47 days
Heart failure and shock w MCC 291 59 days 20.9 days +38 days
Pulmonary edema and resp. failure 189 57 days 22 days +35 days
Trach w MV 96+hours 004 57 days 43 days +14 days
Cellulitis 603 54 days 18.5 days +36 days
Kidney and UTI 690 52 days 18.7 days +33 days
Length of Stay Analysis: LTAC
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Data Analysis Support and Tracking
• PEPPER: The Program for Evaluating Payment Patterns Electronic Report (PEPPER) is a comparative data report that provides hospital-specific Medicare data statistics for discharges vulnerable to improper payments
• PEPPER can support a hospital or facility's compliance efforts by identifying where it is an outlier for risk areas
• This data can help identify both potential overpayments as well as potential underpayments
http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Data-Analysis/index.html
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PEPPER Report Readmission Rates Example
Target Description Number of target
discharges
Percent Hospitaljurisdiction
%ile
Hospital state %ile
Hospital national
%ile
30-day readmission to same hospital or elsewhere
Proportion of index admissions within 30 days
186 25.1% 95.2 94.8 98
30-day readmission to same hospital
Proportion of index admissions within 30 days
105 14.2% 76 75.1 67.2
One-day stays excluding transfers
Proportion of discharges with length of stay less than or equal to one day
28 3.7% 5.5 5.7 2.2
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Readmission Rates
Connecticut Health Team, Hospitals to Face Penalties for High Readmission Rates.Lisa Chedekel, November 27, 2011.
Hospital Pneumonia Readmission RatesPneumonia readmission rates for some Connecticut hospitals have been deemed “worse than” the national average, which could lead to Medicare penalties starting next year:
18.2%
22.2%
21.5%
20.5%
20.3%
18.3%
23.1%
21.4%
20.8%
20.9%
18.4%
23.3%
20.7%
20.5%
20.3%
National Average
Hospital of St. Raphael
Yale-New Haven
Midstate Medical Ctr
St. Francis Hospital
2010
Hospital of St. Raphael
Yale-New Haven
Midstate Medical Ctr
St. Francis Hospital
National Average
Hospital of St. Raphael
Yale-New Haven
Midstate Medical Ctr
St. Francis Hospital
2009 2011National Average
“Worse than” “No different than” Source: Centers for Medicare & Medicaid Services Hospital Compare data
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Severity of Illness
• Assignment of severity of illness and risk of mortality subclasses is based upon a number of factors, including the underlying base APR-DRG assignment (determined by principal diagnosis, principal procedure, age, sex, and discharge status), secondary diagnoses, and interactions amongst secondary diagnoses
• Severity of illness and risk of mortality subclasses are numbered as either 1 (minor), 2 (moderate), 3 (major), or 4 (extreme)
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Capturing Severity of Illness
Low SOI
• Acute respiratory failure• UTI secondary to sepsis• Type 2 DM uncontrolled
• COPD with chronic respiratory failure
• Community acquired pneumonia and aspiration pneumonia
• Hypernatremia
• Malnutrition
Greater SOI captured
• Severe hypoxia• Urosepsis• DM, poorly controlled
• Severe COPD on chronic O2
• Community acquired pneumonia and dysphagia
• Serum Na of 145 mEq/L
• Cachexia
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APR-DRG Summary
MDC/APR MDC
4 severity of illness subclasses
1=Minor
2=Moderate
3=Major
4=Extreme
4 risk of mortality subclasses
1=Minor
2=Moderate
3=Major
4=Extreme
Subclasses of APR‐DRG
316 in total
1,258 subclasses
1,258 subclasses
3-M 2007
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Value-Based Purchasing
VALUE = Quality
Cost
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Bundled Payments
• In January, CMS officially launched one of its biggest financial innovation programs under healthcare reform, a program in which more than 500 hospitals, health systems, and other providers have enrolled: Bundled Payments for Care Improvement.
Bundled Payment for Care Improvement (BCPI) is building off CMS' experiments with bundled payments—the concept that healthcare providers receive a lump sum from the payer.
• Documentation that drives the principal diagnosis as well as complications, exacerbation of comorbid conditions, and LOS will help to decide the sum to be shared.
The Bundled Payments for Care Improvement Program: A Hospital AnalysisWritten by Bob Herman | February 14, 2013 Social Sharing
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Payments
Hospital
Attending
Consultants
Surgeon
Other
A Slice of the Pie
One payment for all to share!Driven by diagnosis-related group.
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Hypothetical Example
Peritoneal infection with MCC
Peritoneal infection with CC
Peritoneal infectionwithout CC/MCC
RW: 2.02 RW: 1.22 RW: 0.840
$16,160 $9,760 $6,720
Simple math: Which amount would you rather share?(based on base rate of $8,000)
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Pay for Performance
"Pay-for-performance" is a term for initiatives aimed at improving the quality, efficiency, and overall value of healthcare.
• This includes financial incentives that reward providers for the achievement of a range of payer objectives, including delivery efficiencies, submission of data and measures to payer, and improved quality and patient safety.
• Medicare will begin withholding 1% of its payments to hospitals and physicians starting in October 2012. That money—$950 million in the first year—will go into a pool to be doled out as bonuses to hospitals and physicians that score above average on several measures.
Pay for Performance (P4P): AHRQ ResourcesAgency for Healthcare Research and Quality website: www.ahrq.gov
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Pay for Performance
Scoring providers for payment distribution purposesAnticipated approaches to scoring provider performance for payment purposes (these approaches range from simple to complex point calculations, paying providers for one or a combination of the following scoring systems):
• Threshold scoring: This simple scoring approach is based on a provider meeting or exceeding a threshold.
• Scoring based on rank: Another approach is to rank providers on a statistical distribution. Payment is increased for providers who perform in the top tier, but decreased for those who perform in lower tiers.
• Tiered scoring (threshold and ranking): This approach provides some reward for progress towards a specific set of goals. The provider has to achieve compliance or exceed a threshold across multiple domains, not just one or two measures.
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A Physician’s Perspective!
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How to Help?
• Discover a physician’s level of CDI knowledge with:– SOI
– ROM
– DRG
– CMI
– MCC
– CC
– HACs
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Educate Your Doctors
• Problem-specific—make sure your doctors know to put the diagnoses into the chart at least once (best if diagnosis flows throughout the record without conflict) and in the discharge summary
• Secondary diagnoses– 1,096 MCC
– 4,221 CC
– 8,232 non-CC* CMS is betting you can’t remember them all!
* CC capture rate down 37% per CMS since MS-DRGs began October 1, 2007
MCC CC No SOI
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Impact of Secondary Diagnoses on APR-DRGs
Sample 1 Sample 2 Sample 3 Sample 4 Sample 5
PDx:Pneumonia
PDx:Sepsis
PDx:Sepsis
PDx:Sepsis
PDx:Sepsis
MS-DRG 194 MS-DRG 871 MS-DRG 871 MS-DRG 871 MS-DRG 871
SDx:Bacteremia
SDX:Pneumonia
SDx:PneumoniaDiastolic CHF
SDx:Klebsiella pneumoniaDiastolic CHF
SDx:Klebsiella pneumoniaDiastolic CHFAcute resp. failure
APR-DRG 139SOI 2ROM 1
APR-DRG 720SOI 2ROM 2
APR-DRG 720SOI 2ROM 3
APR-DRG 720SOI 3ROM 3
APR-DRG 720SOI 4ROM 4
Source: 3M APR-DRG Classification System
Medical Example
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Educate Your Doctors
• Educate doctors that “insufficiencies” do not impact severity of illness (SOI)
• Educate physicians to document all disease processes appropriately– Use/develop CDI pocket cards
• Caution physicians on use of term “postop”: – Often coded as a complication of
procedure/surgery
– The operator or surgeon may suffer the rating drop
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Educate Physicians
• Principal diagnosis– The condition after study to be chiefly responsible
for occasioning the admission to the hospital
• Secondary diagnosis– Conditions that consume one of the following:
• Clinical evaluation• Therapeutic treatment• Diagnostic procedures/testing• Extended length of stay (LOS)• Increased nursing care and/or monitoring
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Educate Physicians
• Principal diagnosis– Caution: hospital-acquired condition (HAC)
– Must be documented if present on admission (POA)
– Monitor HAC data for your doctors
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Hospital-Acquired Condition (HAC)
• Foreign object retained after surgery• Air embolism• Blood incompatibility• Stage III & IV pressure ulcers• Falls & trauma• Manifestations of poor glycemic control• Catheter-associated UTI• Vascular catheter-associated infection• Surgical site infection after CABG, bariatric, or
orthopedic surgery or AICD• DVT or PE• Iatrogenic PTX with venous catheterization
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Hospital-Acquired Condition (HAC):Example
• Patient admitted with ESRD and a dialysis catheter• Patient met the SIRS criteria
– Febrile 101.6 ─ Tachycardia 134
• Nighttime hospitalist on H&P diagnosed– Febrile Illness
• ID consultant subsequently diagnosed– Probable line sepsis
Educate your physicians:“Sepsis possibly due to dialysis access, present on admission”
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Case Study
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H&P (3 Full Pages)
• 83-year-old male admitted with a GI bleed from hemorrhoids
• Hgb 7.8• A/P
– GI bleed – transfused 3 units and given IVF– CHF – given IV lasix– Hyperlipidemia – continue PO meds– DM 2 – SSI– Hypothyroidism continue PO meds– BPH– HTN– Renal insufficiency– History of glaucoma
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Coding Summary Form
• PDx: Hemorrhoids NOS w complication NEC
• Coded to DRG 254 (Other digestive system diagnosis with MCC)
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Documentation Opportunities
• GI bleed with Hgb 7.8– Acute blood loss anemia
• CHF– Acute vs. chronic, systolic vs. diastolic
• Renal insufficiency with SCr 1.8– Acute kidney injury – KDIGO
Missed opportunities to show accurate SOI & ROM
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DC Summary (3 Full Pages)
• D/C diagnoses– HTN– History of DM 2– History of CHF both systolic & diastolic– History of BPH– History of hyperlipidemia– History of glaucoma– History of stage III lung cancer– Severe upper GI bleed, possibly from AVMs– Lower GI bleed from hemorrhoids– Renal failure secondary to dehydration and GIB– Acute upper GI bleed– Myocardial infarction– Deceased on 8/29/2013– Aortic stenosis
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Patient Died on Day 3
• Pt developed significant GI bleed • Transferred back to the ICU• Losing significant blood• Resuscitated with packed RBCs• AVMs• Developed hemodynamic instability
– Given IVF– Resuscitated
• Hypotensive• Placed on vasopressors• Code blue called • Appeared to have an MI• CPR and ACLS but passed away
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Where Are the Diagnoses?
Educate your physicians that documentation that is a narrative needs to contain diagnoses
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What Diagnoses Were Missing?
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Diagnoses That Add to the SOI & ROM
• Acute blood loss anemia
• Hemorrhagic shock
When reviewed using the APR-DRG the SOI and ROM increased from 3 & 3 to 4 & 4
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Documentation Opportunities
• DC summary dictated 30 days after death– Met medical staff bylaws requirement but not
used for coding
– Coders expected to complete and bill chart in about 5 business days
• “History of” used 18 times in the DC summary– May lead to inaccurate coding
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Physician Quality Ratings
• Predicted mortality rates for some disease processes:
– Community-acquired pneumonia = 10%
– Sepsis = 20%
– Severe sepsis = 30%
– Septic shock = 50%
• If the patient survives, physician ratings will be much higher in the public quality reporting data because you took care of a sicker patient
– Physician expected mortality bar will be higher than actual mortality bar
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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.