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8/19/2016

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Using the Health Information Supply Chain (HISCSM) Process to Improve Documentation and Avoid Denials

Dr. Harry FelicianoSenior Medical Director

&Kathy Merrill

President, Agilency

August 30, 2016

• The HISCSM Approach

• HISCSM for Hospice and Palliative Care

• The Organizational Process Improvement Coaching Project (OPICP)

• Flow, timing & accuracy of work to document hospice claim

• Qs & As

Presentation Outline

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• Uses a new unit of analysis for healthcare process improvement and quality management

• Being analyzed by Palmetto GBA, process engineers and Medicare providers in JM

The HISCSM Approach

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• Medicare providers contribute to the Health Information Supply Chain (HISC)

• Coders, billers, and payers are downstream recipients of their health care records

• Records containing insufficient information are ineffective and produce inefficiency

• Denied payments

• Delayed payments

Rationale for the HISCSM Approach

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• Medicare providers' documentation must support both clinical and administrative tasks:

– Capturing the unique attributes of individual patients

– Communicating the individual needs of patients

– Informing clinicians’ decisions

– Informing claims payment decisions

– Informing improvements in both provider and payer

• Policies

• Procedures

Rationale for the HISCSM Approach

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• Goal: Align hospice payment/resource utilization

• Two Routine Home Care (RHC) payment rates

• < 60 days

• > 60 days

• Service Intensity Add-on (SIA)

• Additional payments for RN or social work services provided “during last 7 days of the beneficiary’s life”

CMS Hospice Payment Reform

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• Hospice-related metrics include:

• Hospice diagnosis reporting – number and categories

• Lengths of stay (LOS)

• Live discharges at or around day 61 of hospice care

• Spending for Parts A, B, & D during hospice election

CMS Monitoring Medicare Utilization

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• Alzheimer’s was #1 hospice principal diagnosis

• Replaced Debility unspecified

• Average LOS higher for certain principal diagnoses

• Alzheimer’s disease

• Non-Alzheimer’s Dementia

• Parkinson’s disease

• Principal diagnosis is of potential relevance to future case mix systems for hospice (CMS-1652-P)

https://www.federalregister.gov/articles/2016/04/28/2016-09631/medicare-program-fy-2017-hospice-wage-index-and-payment-rate-update-and-hospice-quality-reporting

FY 2015 Principal Diagnosis

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• Established Policy: The principal diagnosis reported on the claim should be the diagnosis most contributory to the terminal prognosis.

• As of October 1, 2014 “Debility” (799.3, 780.79/R53.81) and “adult failure to thrive” (783.7/R62.7) are not to be used as principal hospice diagnoses on the hospice claim form

Invalid Principal Diagnoses Codes

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https://www.federalregister.gov/articles/2016/04/28/2016-09631/medicare-program-fy-2017-hospice-wage-index-and-payment-rate-update-and-hospice-quality-reporting

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• Several dementia ICD-9-CM/ICD-10-CM codes have principal diagnosis code sequencing rules.

• Most of these dementia codes are found under Chapter 5 of ICD-9-CM/ICD-10-CM classification, “Mental, Behavioral, and Neurodevelopmental Disorders” and are typically manifestations from an underlying physiological condition.

• Example: ICD-9-CM 304.8 , Other persistent mental disorder due to condition classified elsewhere (ICD-10-CM = F06.0)

Additional Invalid Principal ICD Codes

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• Who does it?

• What do they do?

• When do they do it?

• Where do they record it?

• How do you communicate it?

Selection of Principal Diagnosis

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• Partners in ExcellenceSM

• The Hospice Organizational Process Improvement Coaching Project (OPICP) is a collaboration among:

• Palmetto GBA

• JM hospice providers wanting to improve their process flow

• Process engineers - Agilency

The Hospice OPICP

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• Goal: To improve the effectiveness and efficiency of the Hospice & Palliative Care health information supply chain.

• Objectives: To understand current organizational process flows and how hospice organizations select and represent the concepts of “terminal illness” and “related conditions” in their records.

The Hospice OPICP

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Methodology

DESIGN

•Define business requirements•Map the process from patient referral to claim processed•Identify Critical to Quality (CTQ) customer & process elements

MEASURE

•Identify measures for evaluating process performance

•Implement a data collection plan

•Identify process baseline capability

•Collect data on process defects & variation

ANALYZE

•Analyze process flow

•Identify critical path; value/non-value added steps

•Identify sources of errors & variation

•Validate root causes

IMPROVE

•Generate solutions & select options to pilot

•Prioritize deployment of solutions

•Implement solution within 60 days

•Collect data to verify improvement

CONTROL

•Institute a dashboard/scorecard process

•Create feedback loops

•Document standard operating procedures

•Continuously improve

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• A flowchart is a picture of the separate steps of a process in sequential order.

• Elements that may be included are:

• Sequence of actions

• Inputs and outputs

• Decisions that must be made

• People/departments who become involved

• Time involved at each step and/or some other process measurements

A Place for Process Flow Charts

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Sample Hospice Process Flow “Current State”

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• Capture the steps of the process currently performed

• Discover process flow barriers, such as:

• Unclear hand-offs

• Errors prone activities

• Duplication/redundancy

• Vague patient assessment

Baseline Process Flow & Analysis

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Barriers are Needles in a Haystack

Hospice Barrier Examples

Staffing

Patient Staffing Ratio

Weekend staffing minimal

Long admissions

Call volume

Referral staff role

Data Collection/Entry

Rework

Timely submission

Accuracy of information

Waiting for physician input/signature

Paper versus technology

Billing

Incorrect patient information

Confusing payer criteria for claim

submission

Inadequate clinical documentation

Payer response time

Age of documentation

Admissions

Response time

Travel time

Difficulty obtaining medications

Timely & accurate physician input

• Identify Barrier Root Cause

• 5 Whys

• Fishbone Diagram

• Pareto Analysis

• Modified Affinity Analysis

• Hand Off Analysis

• Flow Diagraming

• Isolate ‘Myths’ for elimination

• Attack fixed procedural steps that are outdated or not

applicable

• Make workplace and problems visible

• Define new plays to drive efficiency & effectiveness

Create Future State

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Define the Plays

Referral Assisted Living- Gather info/order- Contact doc for

med rec- Call family-consult

Initial Referral Types: phone calls/Email/Walk-in

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Referral Dr. Office

- MD office fax order

- Call family to set up eval

Referral Hospital

- Pull from referral & order

- Schedule consult/eval for D/C work more w/social worker

- Identify attending.

Referral Nursing Home

- Gather info/order- Call family/consult- Work more with social

worker

AdmissionsFace to Face;

determine need; schedule

Co

din

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Clin

ica

lS

taff

Referral Family

- Contact doc for order /H&P

- Set up appointment for call

ITEnter referrals & leads. Use

pending reason to

differentiate.

ITAC enters patient

data at referral

ITVerify patient

insurance

information,

coverage, benefit

period

ITEnter insurance

information &

bil l ing sequence

Admitting Nurse

Completes admission

assessment

Admitting/ On call RNConsult with physician to

determine Dx

Admitting/ On call RN

Reports admissions to Clinical Staff

2 3

4 56 7

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1

8

17

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HISCSM Generated Future State Hospice Flow

= Improvement InitiativesCritical Path

IT

10

AdmissionsBuild chart in

binder as Admissions

gathers paperwork

ITEnter Dx + 2nd Dx

Re

venue C

ycle

sta

rts h

ere

AdmissionsAdmit patient into Hospice

Pre Admit Triage – obtains patient info , verify ins; tee-up

family what is needed; schedule legals

1120

PCM/IDGDiagnosis list

PCSCompile

documents for Clinical

Staff

PCSFax Med list to Pharmacy

PCSEnter admissions to

roster; enter admission to RN;

MSW; Chaplain; HA schedules

ITWeekly recurring

charge generator to Revenue Coordinator

ITDiagnoses List in GL with

ability to evaluate & document relatedness…

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15 17

23

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25

30

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ITVisiting Entry: CM;

Hospice Aid; M&W; SC

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Medical RecordsCompiles chart; checks for compliance; Face Sheet

12

SCR/ACFax clinical & other

documents to Attending

ITData entry of HIM information; enter

disciplines

SCR/ACTechnical review of consents & clinical

documentation

ITEntering ongoing LOC

changes; Enter Location changes; Enter BP events

238/30/2016

• “This is the first time we’ve looked across all functions and can see the process from patient presentation to payment.”

• “This is the first opportunity we’ve ever had to bring the whole team together and look at the big picture.

• “We’ve been working really hard to get it right. Now we know what “it” is and what to work on.”

Testimonials to OPICP Collaboration

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• The process varies among hospices

• This variation can contribute to errors and waste

• Rework increases costs for both payers and providers

• Incorrect selection of hospice principal diagnosis will impact financial performance in a case mix system

• Preventing the errors is our goal

Selection of Principal Diagnosis

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• Communicating biopsychosocial concepts in support of hospice and palliative care, requires a knowledge of payer design requirements (eligibility and coverage standards) and your organizational workflow

Framing the problem

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• When considering the initial certification of terminal illness do you have the necessary information to make decisions related to:

• Principal diagnosis

• Related diagnoses

• Current subjective and objective medical findings

• Current medication and treatment orders and

• Unrelated conditions

How is your organization doing?

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• What’s in it for us?

• More efficient operations

• Happy customers

• CMS

• Providers

• Beneficiaries

• Decrease overall waste in our healthcare system

Getting it Right the First Time

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• Is important to both providers and payers

• Will inform CMS payment reform activities

• A pre-requisite for communicating the concepts of “terminal illness” and “related conditions”

An Accurate Principal Diagnosis

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Re

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Referral Dr. Office



Referral Hospital






worker

AdmissionsFace to

Face; determine need;

schedule

Co

din

g

Clin

ica

lS

taff

Referral Family




pending reason to

differentiate.

ITAC enters patient

data at referral

ITVerify patient

insurance

information,

coverage, benefit

period

ITEnter insurance

information &

bil l ing sequence

Admitting Nurse

Completes admission

assessment


determine Dx



2 3

4 56 7

9

1

8

17

18

19

21

22

26

27

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IT

10



gathers paperwork

ITEnter Dx + 2nd Dx

Re

venue C

ycle

sta

rts h

ere


Pre Admit Triage – obtains patient info , verify ins; tee-up family what is needed;

schedule legals

1120


PCSCompile


Staff





ITWeekly recurring



ability to evaluate &

document relatedness…

13

1416

15 17

23

24

25

30

31

32



30


12




disciplines


documentation



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• In addition to accurate substantive clinical documentation is the administrative process flow to effectively & efficiently collect & organize documentation for claim submission.

• Linking together clinical & administrative tasks will reduce the waste driving up the cost of the episode. Costs include rework, response time, ‘hunting’ & waiting, for example.

Connecting the dots

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Re

ferr

als

Adm

issio

ns

On c

all

Nu

rse

Secre

tary

Site R

evenue

Co

ord

inato

rM

ed

ica

l R

eco

rds

Referral Dr. Office



Referral Hospital






worker

AdmissionsFace to Face;

determine need; schedule

Co

din

g

Clin

ica

lS

taff

Referral Family




pending reason to

differentiate.

ITAC enters patient

data at referral

ITVerify patient

insurance

information,

coverage, benefit

period

ITEnter insurance

information &

bil l ing sequence

Admitting Nurse

Completes admission

assessment


determine Dx



2 3

4 56 7

9

1

8

17

18

19

21

22

26

27

28



IT

10



gathers paperwork

ITEnter Dx + 2nd Dx

Re

venue C

ycle

sta

rts h

ere


Pre Admit Triage – obtains patient info , verify ins; tee-up

family what is needed; schedule legals

1120


PCSCompile


Staff





ITWeekly recurring



ability to evaluate & document relatedness…

13

1416

15 17

23

24

25

30

31

32



30


12




disciplines


documentation



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Resource Utilization

relative to > 60 day

episode payments

08/30/16

• January 1, 2016 RHC rate (Days 1-60) $186.84

• January 1, 2016 RHC rate (Days 61+) $146.83

Resource Allocation vs Payment

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• Optimizing process flow by understanding the HISCSM

approach provides the ability to separate direct versus burden (overhead) costs.

• Standardizing direct resource tasks to reduce variation drives out waste & improves process flow. This provides clinicians the ability to do more with their time.

• Comprehending waste in burden or overhead leverages the indirect resources to improve capacity – example, less rework in billing increases the number of claims handled the first time shortening the cycle time to submit a claim from date of referral.

Resource Cost Relative to Process Flow

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• Palmetto GBA has established #MedicareHISC

• https://twitter.com/hashtag/medicarehisc

• Can be used on-line to search and follow the discussion regarding the Medicare health information supply chain

• Search term = #MedicareHISC

Using the #MedicareHISC hashtag

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Harry Feliciano, MD, MPH

Attn: Medical Affairs, AG-275

Palmetto GBA

PO Box 100238

Columbia, SC 30202-3238

[email protected]

Qs & As

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Kathy Merrill, MBA, Lean, WOSB

Agilency

705 Pearl Beach

Coldwater, MI 49036

[email protected]

https://twitter.com/hashtag/medicarehisc

mailto:[email protected]

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