Quality & Documentation
For Heart Failure & AMI Programs
Nathalie De Michelis, Cardiovascular Program Manager
July 24th, 2014
Heart Failure Program
Inpatient and Outpatient FY 2013-2014
Formal outpatient HF Clinic program
• 1535 HF clinic visits
– 551 single pts
Inpatient visit volume
• 174 PDx of AMI
• 254 PDx of HF
– 254 with 2nd Dx w/ Acute HF
Discharge Unit & Services
• for Primary HF Dx
HF DC Service
HF DC Unit
0.39%
5.5%
1.18%
10.2%
26.0%
47.24%
34.3%
50.00%
23.2%
0.4% 0.4%
CCU/MICU
2
DH78
ED
SICU
T3
0.39%
T5
TELE/SDU
CARD
CTSx
FM
IM
0.79%
SURG
TxSx
CV Program Design…
Coordinated Care Across the Continuum (In-patient)
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ED triage (CP unit, CP/AMI & HF Algorithms)
Identifying patient population/AMI & HF program introduction
Multidisciplinary Clinical Pathways
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EBT Cardiology Order Sets Please try to use
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HF & PCI
A fib, AMI, CP, EP, HF, Cath, PCI
Initiation of patient education process by HF NP & HF Coach
State-of-the-art diagnostics
Collaborative input for advanced treatments:
• interventional, device, surgical therapies, cardiac anesthesia
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Comprehensive discharge plan/case mgmt
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f/u with in a week, Home Health when eligible,….
Palliative care/end of life
Research pool
CV Program Design…
Coordinated Care Across the Continuum(Out-Patient)
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UCI Cardiac Rehab
Cardiology Clinic
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HF Clinic
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General Cardiology
EP/Pacemaker Clinic
Valve Clinic
Woman Card Clinic
Adult Congenital Clinic
CV Preventive Clinic
Open access & program follow-up
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Timely post-discharge HF recommendations to PCP
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HF Program f/u of moderate-advanced HF
IV Lasix
48 hrs and 1 month follow-up phone calls  to prevent ED Readmit
HF & DM Chronic Disease in person Coach Care
Palliative Care Collaboration soon…HF/Palliative clinic
Research pool
HF & AMI List
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HF/AMI List
• Communication tool, between the HF Program
Manager & the care team, to assist with the
identification & the care of this population
• Let me know if patients need to be added or
deleted from the list below.
• Please clarify pink areas on the patient list
• Memorandum of Agreement between IM &
Cardiology for HF for Heart Failure Patients
• New Onset HF Admit to Card Service
• Acute HF following in UCI Card Admit to Card
• Other Acute HF  request a Card consult
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Quality Initiatives
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Joint Commission Certified HF Program since 2008
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Dr. D. Lombardo Medical Director
OC Cardiovascular Receiving Center since 2005
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Dr. P Patel Medical Director
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Multiple National & State Quality Initiatives
– American Heart Association (Gold Plus HF AHA award)
– American College Of Cardiology
– CMS & Joint Commission Measures
– Readmission Reduction Task Force
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DSRIP projects
– Improvement of Primary Care in HF & DM
Disease management
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Research
What are Hospital Quality Measures
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Measures based on:
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Scientific evidence
Reflect guidelines
Standards of care or practice parameters
Converts medical information from patient records
into a rate or percentage that can be assess
Why quality measure are important?
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Use to assess:
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How well care is provided to our patient
Our performance over time
Helps improve patient care
Benchmark for outcomes & resource utilization
(Internal, External , Public)
Public Reporting
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CMS & The Joint Commission
Healthcare consumerism
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CMS.gov (Hospital Compare), Healthgrades.com, WebMD.com, State
organizations
Pricing, Payment and Contracting
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Quality data used by insurers in negotiating contracts
Rate affect Reimbursement rate
Pay-for-performance, VBP, Readmission Reduction Program
Physician Quality Reporting System (PQRS), HEDIS
AMI Hospital Quality Measures - CMS, TJC
• Outpatient Arrival time to ECG & Troponin for CP
• Aspirin within 24 hrs of Arrival (or clear documented contraindication)
• PCI Within 90 Minutes of Arrival for STEMI
• Fibrinolytic within 30 Minutes of Arrival for STEMI (not used at UCI)
• Discharge on (or clear documented contraindication if not)
• Aspirin
• ACE or ARB for LVSD
• Beta Blocker
• Statin
• AMI 30 days Mortality rate
• AMI 30 days Readmission rate
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AMI Composite
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AMI 30 Day Readmission rate
AMI - % 30 Day Readmit
% 30 Day Readmit
UHC Top 25th Percentile Performance
35.00
30.00
Percentage
25.00
20.00
15.00
10.00
7.3
5.00
0.00
Discharge Month
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Hospital compare for AMI- PCI & ASA-CP measures
http://www.medicare.gov/hospitalcompare/search.html
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Hospital compare - HCAHPS
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HF Hospital Quality Measures
% of HF patients given:
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Discharge Instructions (need all 6 items)
• Diet  Cardiac diet  be more descriptive – i.e. 2g low salt, low fat….
• Activity level
• Daily Weight Monitoring  Even if on Dialysis
• Medications (complete reconciliation w/home & hosp. Rx
• with indication for each Rx (NEW TJC measure)
• Symptom management
• Recommend pt to call if weight gain is >3lbs in a day or > 5lbs in a week
• Follow-up appointment (with date and time on DC Instruction)
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Documentation of LVS function
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ACE or ARB for LVSD at discharge (or clear documented contraindication)
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HF 30 days Mortality rate
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HF 30 days readmission rate
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HF TJC & AHA GWTG Measures
• DVT Prophylaxis while in hospital
• Prior to Discharge on (or clear documented contraindication if not)
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Pneumococcal Vaccination
Influenza Vaccination During Flu Season
ICD Placed or Prescribed
For EF≤ 35 (exclude new onset):
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ICD Placed or Prescribed
CRT-D or CRT-P Placed or Prescribed if QRS ≥120 or QRS ≥ 150 or LBBB
• Discharge on (or clear documented contraindication if not)
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Evidence-Based Specific Beta Blockers for LVSD (Bisoprolol, Carvedilol, Metoprolol CR/XL)
Aldosterone Antagonist
Anticoagulation for Atrial Fibrillation
Hydralazine Nitrate ( for African Americans on OGMT)
• Post Discharge Appointment (including date, time, location; or home health visit)
• Follow-Up Visit Scheduled Within 7 Days or Less
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HF Hospital Quality Measures –
HF Composite
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Hospital compare for HF
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GWTG Achievement & TJC Measure –
Evidence-Based Beta Blockers
[TJC Target 90%]
[GWTG Target 85%]
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GWTG Achievement & TJC Measure –
Aldosterone Antagonist for LVSD at DC
[GWTG Target 75%]
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GWTG Plus Quality Measure
Anticoagulation for A. Fib
[GWTG Target 75%]
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GWTG Achievement Measure
Follow-up at Discharge (with date, time & location)
[Target 85%]
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HF 30 Day Readmission rate
HF - % 30 Day Readmit
% 30 Day Readmit
UHC Top 25th Percentile Performance
60.00
50.00
Percentage
40.00
30.00
20.00
16.6
10.00
0.00
Discharge Month
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How to improve HF/AMI measures &
outcomes?
How to improve HF/AMI measures?
• Treating all present health issues
• Make sure well compensated when DC
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Education during hospital stay- Patient should be familiar &
competent with:
Condition
Medication
Symptom Management
Life style change
Importance of follow-up ( to prevent no show)
Proper Documentation of Guideline therapy
• or explicit contraindication
– i.e. ACE & ARB contraindicated at this time due to worsening renal function
– i.e. Not on anticoagulation for A. Fib due to active GI bleeding
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Proper Documentation of conditions & procedures
• as it affect Coding
How to improve HF/AMI measures?
• Use Disease Specific Order Set
• Proper Discharge
– Medication Reconciliation
– All needed components are on Discharge instructions
– The discharge summary document must contain
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Provider contact information
Discharge date
Discharge Diagnosis
Updated summary of the patient’s hospitalization.
Pending labs, test and imaging
Other follow-up issues for next provider
Complete set of discharge instructions
Discharge Process
• Proper transition of care
– Early follow-up (7 days post dc with PCP & needed specialties)
• Give Date & time of appointment before discharge
– Prompt transfer of hospitalization information
• to PCP or to next care provider
– Access to care and medication
– Refer to Home Health, Cardiac Rehab, Telemonitoring
– Refer to free UCI Patient education classes.
• HF, Heart Diet, DM, HTN
• The discharge summary creates the Discharge
instructions
• Be certain the nurse provides the patients with the FINAL version
• must notify nurse if there are any last minute changes
• Go over the instructions with the patient/family
• Fax/e-fax/mail discharge summary to the next care provider
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Last chance to meet measures
Memory Aids &
Discharge note –Core Measures
Memory Aids
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Memory Aids
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UC Irvine Health
The importance of
Clinical Documentation
Why should we care?
Documentation drives:
• The levels of coding, billing and reimbursement
• Measure Compliance
• Severity of Illness (SOI) and Risk of Mortality (ROM)
• Measures by which healthcare organizations & healthcare providers are
evaluated and ranked
• Stay competitive in the market
• Insurance Companies’ Contracting
• General public shopping for care
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Due to trend of greater transparency & availability of clinical performance
data, on internet websites (e.g. Healthgrades, hospital compare)
• Prevention of random audits by the government
• and serves to support the care provided by a healthcare provider in such
an event
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• Reduce liability in the event of legal action
Surfing for Quality of Care and Prices
http://hospitalcostcompare.com
Hypertension Without Major Complications
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Hospital & Physician Report Cards
Healthgrades.com
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Medicare.gov/hospitalcompare
One thing leads to the next
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Documentation
ICD Code
DRG (Diagnosis-Related Group)
Severity adjusted DRG
Severity of illness & Mortality data
Observed mortality
Expected mortality
(From severity adjusted DRGs)
Outcomes + Accurate Documentation = Quality
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What is a DRG and how does it work?
• Identifies the "products" that a hospital provides
• DRGs have been used in the US since 1982 to determine how
much Medicare pays/reimburses the hospital for each "product“
• It is similar to a known recipe:
• Each DRG has a relative cost weight & expected LOS
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DRGs
• DRGs that are associated with a higher frequency of mortality
are frequently under documented in regard to severity of
illness
• i.e. heart failure, pneumonias, urinary tract infections, & malignancies
• Example:
• Patients have who that have respiratory failure and cardiac arrest
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Most go into Hypotensive shock and have com. respiratory failure
• So if would document these
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it would change the MS-DRG
and improve predicted mortality measures
Inherently, the MSDRG system penalizes rushed documentation
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SOI, ROM, CC & MCC
• Every patient we treat  get assigned a SOI & ROM rate based
on the documentation between 1 and 4 .
-1: Minor - 2: Moderate -3: Major -4: Extreme
• Secondary Diagnosis Coding Rule and impacts:
• DRG Assignment, Severity of Illness/Risk of Mortality Reporting; and
Organization and Physician Profiling, evaluation and ranking.
• Documentation of Diagnosis with severity (Acute, Acute on
Chronic or chronic) instead of signs and symptom
• assist with CC/MCC, SOI & ROM
• Important to document in detail the CCs
• All co-morbidities (Condition present on admission)
• All complications (Condition that develop after admission)
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Cardiac Diagnosis
(Dx with** are not counted if patient expires)
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Respiratory Diagnoses
(Dx with** are not counted if patient expires)
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Case Example 55 y/o female LOS 11 days - expired
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When ≥ 3 different organs are affected  start to see MCC
Heart Failure DRGs Comparison
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3MMS DRG 285 AMI, expired w/o CC/MCC
Dx suggestion to consider
M= Affect DRG
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S=Affect Severity
R=Affect Mortality
MSDRG are assigned a mortality risk model
• Using specific variable descriptions
• The mortality is than calculated and give us:
• our expected morality rate versus actual observe mortality
• The goal is to have high expected rate for low observe rate
• This rate is used in our data and benchmarking
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Case example risk model 901:
Assigned MSDRG of 285- AMI, expired without Comorbidity or
Complication (CC)/Major CCMortality model 901
Variable Description
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Intercept
Vent on Admission Day
Cardiac Arrest
Shock
Aortic Aneurysm Dissection/Rupture
Female, Age >= 85
Male, Age >= 85
Male, 80 <= Age < 85
Endocarditis
Female, 80 <= Age < 85
Other Pulmonary
Male, 75 <= Age < 80
Female, 75 <= Age < 80
CC Metastatic Cancer
Hypotension
Vfib
Ischemic Stroke
AMI Subsequent
Female, 65 <= Age < 75
Severe Brain/Spinal Conditions
Renal Disease/Failure
Male, 65 <= Age < 75
Acute Liver Disease
Sepsis
Admit Source = Transf From Skilled Nursing/Long Term
Care
CC Fluid & Electr Disorders
CC Peripheral Vasc Disease
Aortic Stenosis
CC Coagulopthy
Admit Source = Transf From Acute
Male, 31 <= Age < 51
Model
Grou
p
Beta
Odds
Ratio
95% Lower
Confidence
Interval
95% Upper
Confidence
Interval
P-Value
901
901
901
901
901
901
901
901
901
901
901
901
901
901
901
901
901
901
901
901
901
901
901
901
4.452
1.938
1.816
1.589
1.520
1.418
1.393
1.195
1.027
0.979
0.887
0.795
0.769
0.760
0.724
0.702
0.631
0.576
0.563
0.562
0.521
0.473
0.441
0.437
6.943
6.149
4.897
4.571
4.127
4.026
3.304
2.793
2.661
2.428
2.214
2.159
2.137
2.062
2.018
1.879
1.779
1.756
1.754
1.683
1.605
1.554
1.549
6.137
4.943
4.290
2.763
3.541
3.404
2.738
1.924
2.187
1.571
1.817
1.743
1.658
1.784
1.573
1.350
1.232
1.470
1.479
1.533
1.362
1.234
1.272
7.854
7.649
5.590
7.561
4.811
4.761
3.987
4.054
3.238
3.750
2.697
2.674
2.756
2.384
2.587
2.615
2.569
2.097
2.081
1.848
1.891
1.956
1.886
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.002
0.000
0.000
0.000
0.000
0.000
0.000
901
901
901
901
901
901
901
0.435
0.351
0.261
0.243
0.230
0.225
0.467
1.546
1.421
1.298
1.274
1.259
1.253
0.627
1.211
1.289
1.163
1.114
1.075
1.136
0.477
1.972
1.566
1.449
1.458
1.476
1.381
0.824
0.000
0.000
0.000
0.000
0.004
0.000
0.001
UCI Q1 2014 Clinical Outcome report
Risk-Adjusted Mortality
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AMI case example
Original attestation sheet
SOI of 3 and ROM of 3 (Major)
DRG 285 - Acute myocardial infarction, expired w/o CC/MCC
DRG payment $9117.25
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Documentation correction
Patient chart documentation improvement that affects SOI & ROM:
 Pleural effusion only (would affect SOI)
 Add Acute Diastolic Heart Failure (would give it a CC, and affect DRG, SOI & ROM)
 Intubated
 Instead on a mechanical ventilator (would give it a MCC)
 Fluid overload & Hyperkalemia
 Instead Fluid & Electr Disorders (hyperkalemia) (would affect ROM)
Also to affect DRG, SOI &ROM Prior to arrest could document:
 Com Respiratory failure
 Hypotension shock
 Coma
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Coding attestation post documentation
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SOI of 4 and ROM of 4 (Extreme)
DRG 283- Acute myocardial infarction, expired w MCC
DRG payment $22597.06 (+ $13479.81)
Documentation & coding
• Coders are limited in what they can code
• They are not allowed to “interpret”
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i.e. Hgb 5.0 ≠ to anemia
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Document anemia with specific type, acuity & cause
V Fib, Chest compression, defibtillation, epi …≠ Cardiac arrest/Code
Bacteriemia ≠ sepsis
No response no noxious stimuli ≠ Coma
• Document suspicions to the highest degree known
• Fail documentation often happen when unable to obtain a test
or specimen
• Document what the treatment is based on the clinical picture
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I.e “Suspect G-pneumonia, ….Rx.. given, as unable to obtain a sputum
specimen.”
Do not under-state discharge diagnoses
Heart Failure Documentation
• r/o differential diagnosis if n/a anymore
• i.e. COPS vs HF VS PN. HF is or is no longer the differential
diagnosis for SOB/Volume Overload
• “Likely”= possible coding of that condition
• Determine if it is Right or Left Heart Failure
• RHF = gets coded as 428.00 Unspecified HF , no code exist
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for RHF
Document cause of RHF i.e. RHF 2/2 Cor Pulmonale
iF RHF alone need to meet all measures
Heart Failure Documentation
• Specify to type
• Combine Systolic and Diastolic
• Diastolic
• Systolic
• Do not use systolic alone. Patients with systolic HF also
have diastolic HF
• Specify the acuity
• Acute
• Chronic
• Acute on Chronic most acute HF patients
• Specify the etiology/cause if available (…HF 2/2…)
• Ischemic, Afib, HTN, Valvular,…
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Heart Failure Specificity
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If the type is not document event if acuity is
•  It gets coded as 428.00 Unspecified HF
• i.e. Acute HF = 428.00 Unspecified HF
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A documented EF is not a diagnosis of HF
• EF 30% ≠ not coded as systolic
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CHF exacerbation ≠ not coded as acute
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428.00 Unspecified HF ≠ do not count as a comorbidity
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New HF definition such as HFpEF, HFreF ≠ not coded
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Example proper documentation:
• Chronic Systolic LV dysfunction 2/2 Ischemic Cardiomyopathy
• Acute Diastolic LV dysfunction 2/2 Afib with RVR
• Acute on Chronic Systolic LV dysfunction medication noncompliance
• Right Heart Failure d/t acute Pulmonary HTN 2/2 Cor Pulmonale
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ACS/AMI-Severity issues
• Consist of 3 major clinical entities in a continuum
• Unstable angina
• NSTEMI
• STEMI
• Caution with documentation of:
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ACS alone = gets coded as UA
MI type 2 demand ischemia  gets coded as generic AMI (so needs to meet guidelines)
Otherwise to not document MI. Only Elevated troponin, demand ischemia 2/2….
• Severity issues
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Identify new LBBB
Location of MI
Identify cardiogenic shock
Identify acute or chronic systolic HF when it is present
Hypotension ≠ not codable as cardiogenic shock
Low BP is not cardiogenic shock
Multi organ failure ≠ not codable
STEMI & PCI documentation
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If LBBB, Document if new or old.
• If NEW = STEMI (needs to meet all AMI Measures)
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Document clearly if 1st ECG is STEMI or NSTEMI
– Be consistent through-out the chart
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If PCI delay document:” PCI delay due to…”
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Pt atypical presentation into the ED
r/o aortic dissection prior PCI
Pt hemodynamic and clinical instability requiring stabilization
Difficult access to coronary arteries
Difficult vascular access
Insertion of IABP prior PCI (w/i 90 min of arrival)
Cardiopulmonary arrest (w/i 90 minutes of arrival)
Initial patient/family refusal
Pt wished to delay/wait before starting PCI (initially withheld consent)
Emergent testing required prior PCI
Other [write]
Summary
• Documentation become our data
• key measure of performance
• Correct documentation is critical to improving performance
• It allows you to see where actual problems lie
• Diagnostic statements must be explicitly stated
• Symptoms, orders, treatments, X-ray evidence does not replace a
diagnosis
• Benchmarking allows to compare performance against the
expected averages
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