On the CDI Horizon: CMS' Hierarchical Condition Categories
Vaughn Matacale, MD
Director, Clinical Documentation Advisor Program
Donald Butler, RN, BSN
Manager, Clinical Documentation Advisor Program
Vidant Health, Greenville, NC1
Learning Objectives
• At the completion of this educational activity, the learner will be able to:
– Describe the development and refinements of CMS HCCs
– Identify the current applications of the HCC methodology
– Explain strategies to focus CDI activities on enhancing accurate capture of HCC diagnoses
– List the fundamentals required to begin to incorporate HCCs into daily CDI practice
– Collect knowledge enabling a CDI program to develop the possibility of incorporating HCCs into CDI practice
2
Literature Review
•
Evaluation of the CMS‐HCC Risk Adjustment Model Final Report, Pope et al, March 2011
•
2015 Condition‐Specific Measures Updates and Specifications Report Hospital‐Level 30‐Day Risk‐
Standardized Readmission Measures
•
•
•
•
https://www.cms.gov/Medicare/Health‐
Plans/MedicareAdvtgSpecRateStats/downloads/evaluation_risk_adj_model_2011.pdf
https://www.cms.gov/Medicare/Quality‐Initiatives‐Patient‐Assessment‐Instruments/HospitalQualityInits/Measure‐
Methodology.html
Also includes information at the link for mortality, payment, and readmission measures
ACDIS Conference 2015
–
–
CDI for Risk Adjustment Coding; Adele L. Towers, MD, MPH
Medicare Risk Adjustment, the New Payment Methodology: What Your Physicians Need to Know; Lynn H. Lowery, CPC, CFPC; Trey A. La Charité, MD
•
The Healthcare Executive’s Guide to ACO Strategy, 2nd ed, Feb 2015
•
Florida Hospital Association Medicare Advantage Payment Methodology and Area Rates for Jan–Dec 2015; June 2014
–
•
•
http://store.healthleadersmedia.com/the‐healthcare‐executive‐s‐guide‐to‐aco‐strategy‐second‐edition
https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&uact=8&ved=0ahUKEwjjr6OC9K7LAh
ULaz4KHbBDAwEQFggcMAA&url=http%3A%2F%2Fwww.fha.org%2FshowDocument.aspx%3Ff%3DMAPaymentMethodol
ogy2015.pdf&usg=AFQjCNFp5lfweOsobZjhZDcjMDEcWFNk7g&sig2=wjuGszEWbUNKyQ59szeGaA&bvm=bv.116274245,d
.cWw
The HHS‐HCC Risk Adjustment Model for Individual and Small Group Markets Under the Affordable Care Act, Medicare & Medicaid Research Review, 2014: Vol 4, #3
•
https://www.cms.gov/mmrr/Downloads/MMRR2014_004_03_a03.pdf
3
©2016 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without express written permission.
Introduce, Define, & Discuss
• Historical development and structure
• Areas of refinement or readjustment
• Initial application  current areas of application
4
Historical Development and Structure
• CMS recognized a need to prospectively adjust for anticipated costs that varies across beneficiaries
• Specifically wanted to incentivize enrollment of high‐
risk and high‐cost patients to Medicare Advantage plans
5
Historical Development
• Medicare is one of the largest healthcare programs in the world and has about 50 million beneficiaries. One quarter are enrolled in private health insurance Medicare Advantage (Medicare Part C) plans.
– Medicare Advantage–styled plans have been available on at least a limited basis since 1982
– Medicare Advantage plans are subject to risk‐adjusted capitation payments
– The risk adjustment methodology currently in use is the CMS Hierarchical Condition Categories (HCC) Version 22
6
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Historical Development
• Pooling of risk as well as risk adjustment are fundamental concepts for all types of insurance (or similar programs)
– Pooling of risk among a large population is needed
• To create stable and measurable characteristics that can be used to easily predict future costs
• Spreads the relatively rare risk of high‐medical‐cost events across a large group, so that the majority trade a slightly higher cost of care to protect against catastrophic events and costs
– Risk adjustment methodologies allow for more accurate and predictable cost planning for a given (large enough) population
– Medicare Advantage and ACO/Medicare Shared Savings programs incentivize for both quality and efficiency of care, sharing both the risk and rewards
7
Historical Development
• Medicare risk adjustment models over time & explanatory power as measured by R2
– (percentage variation of individual expenditures predicted)
Risk adjustment model
Payment years
R2
Adjusted Average Per Capita Cost (AAPCC)
Pre‐2000
0.0077
0.8%
Principal Inpatient Diagnostic Cost Group (PIP‐DCG)
2000–2003
0.0550
5.5%
CMS—HCC
2004–2008
0.0997
10%
CMS—HCC Version 12 (2005 recalibration)
2009–2014
0.1091
11%
CMS—HCC Version 21 (2007 recalibration & 2009 clinical revision)
2014–current 0.1246
13%
8
Historical Development
• AAPCC
– Age, sex, Medicaid enrollment, institutional status, working aged status, disability status
– County based, and MA paid 95% of county AAPCC
– Five‐year moving averages of per beneficiary spending at the county level for fee‐for‐service Medicare – Was found to actually increase total Medicare expenditures as MA enrollees healthier than FFS beneficiaries and AAPCC not able to account for this favorable risk selection
• PIP‐DCG
– Intended as a transition model, with the initial inclusion of some sort of health‐based risk adjuster
– Used the most serious principal inpatient diagnosis from the previous year along with demographics similar to AAPCC
– Most serious shortcoming was the restriction to inpatient—no inclusion for outpatient diagnosis or for patients not admitted
9
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Historical Development
• CMS—HCC model
– Developed by researchers with RTI International and Boston University with clinical input from physicians at Harvard
– Incorporates 1 year of diagnosis from inpatient and outpatient settings from a variety of licensed providers
• Physicians, NPs/PAs, … from both hospital inpatient/outpatient and physician office environments
– Easily updated with both ICD coding and clinical changes, as well as with CMS FFS data and experiences
– Diagnosis must be REPORTED every year
• And yes, that does mean if not coded yearly, an above the knee amputation apparently does grow back
10
Historical Development
10 principles
1. Diagnostic categories should be clinically meaningful
– Should all relate to a reasonably well‐specified disease or medical condition that defines the category – Conditions must be sufficiently clinically specific to minimize opportunities for gaming or discretionary coding – Clinical meaningfulness improves the face validity of the classification system to clinicians, its interpretability, and its utility for disease management and quality monitoring 2. Diagnostic categories should predict medical expenditures
– Diagnoses should be reasonably homogeneous with respect to their effect on both current and future yearly costs 11
Historical Development
10 principles
3.
Diagnostic categories that will affect payments should have adequate sample sizes to permit accurate and stable estimates of expenditures – Diagnostic categories should have adequate sample sizes in available data sets – The data cannot reliably determine the expected cost of extremely rare diagnostic categories
4.
In creating an individual’s clinical profile, hierarchies should be used to characterize the person’s illness level within each disease process, while the effects of unrelated disease processes accumulate – Because each new medical problem adds to an individual’s total disease burden, unrelated disease processes should increase predicted costs of care. – However, the most severe manifestation of a given disease process principally defines its impact on costs. Therefore, related conditions should be treated hierarchically, with more severe manifestations of a condition dominating (and zeroing out the effect of) less serious ones. 12
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Historical Development
10 principles
5. The diagnostic classification should encourage specific coding – Vague diagnostic codes should be grouped with less severe and lower‐paying diagnostic categories to provide incentives for more specific diagnostic coding 6. The diagnostic classification should not reward coding proliferation – The classification should not measure greater disease burden simply because more ICD codes are present – Hence, neither the number of times that a particular code appears, nor the presence of additional, closely related codes that indicate the same condition should increase predicted costs 13
Historical Development
10 principles
7. Providers should not be penalized for recording additional diagnoses (monotonicity) – This principle has two consequences for modeling: 1) No condition category (CC) should carry a negative payment weight, and 2) A condition that is higher‐ranked in a disease hierarchy (causing lower‐rank diagnoses to be ignored) should have at least as large a payment weight as lower‐ranked conditions in the same hierarchy 8. The classification system should be internally consistent (transitive)
– If diagnostic category A is higher ranked than category B in a disease hierarchy, and category B is higher ranked than category C, then category A should be higher ranked than category C 14
Historical Development
10 principles
9. The diagnostic classification should assign all ICD‐9/10‐
CM codes (exhaustive classification) – Because each diagnostic code potentially contains relevant clinical information, the classification should categorize all ICD codes 10. Discretionary diagnostic categories should be excluded from payment models – Diagnoses that are particularly subject to intentional or unintentional discretionary coding variation or inappropriate coding by health plans/providers, or that are not clinically or empirically credible as cost predictors, should not increase cost predictions – Excluding these diagnoses reduces the sensitivity of the model to coding variation, coding proliferation, gaming, and upcoding
15
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Historical Development
• Principles 7 (monotonicity), 8 (transitivity), and 9 (exhaustive classifications) were followed absolutely
• There are trade‐offs among other principles
– Clinical meaningfulness (1) drives toward a larger number of detailed groups vs. adequate sample sizes (3)
– Specific coding (5) vs predictive power (2)—if non‐specific codes are excluded, there may be a loss of predictive power
– Excluding discretionary codes (10) can also lower predictive power (2)
• The trade‐offs were approached in model development
– Empirical evidence on frequencies and predictive power
– Clinical judgment on relatedness, specificity, and severity of diagnosis
– Professional judgment on incentives and likely provider responses to classification systems
16
CMS HCC Structure
•
HCC development & structure (V21)
•
•
Hierarchy examples (V22)
Additional HCC weight factors (V22)
– Diagnostic groups, condition categories, & hierarchies
– Demographics
– Disease interactions
• Note, V22 is the current version with ICD‐10, same concepts; differences in specific numbers, example HCC n = 79
• Also some changes in a few of the categories and hierarchies
• Best available reference however discusses V21
17
CMS HCC Version 21 Development
• Additional Medicare risk assessment weight factors
– Demographics
• Age
• Disability status
• Community vs. institutionalized
• Medicaid
• ESRD is separate
18
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CMS HCC Version 21 Development
ICD‐9 codes (n = 14,000+)
Diagnostic Groups (DXGs) (n = 805)
Condition Categories (CCs) (n = 189)
Hierarchies imposed
Hierarchical Condition Categories (HCCs) (n = 189)
CMS Hierarchical Condition Categories (n = 70)
19
CMS HCC Version 21 Development
• Each Diagnostic Group represents a well‐specified medical condition
• Condition Categories describe a broader set of similar diseases that are related clinically and have similar cost
• Finally, the Hierarchies are imposed to ensure that a person is credited (or applied weight) with the most severe manifestation of related diseases
• HCCs are also grouped from an organizational standpoint into body systems
20
CMS HCC Hierarchy Structure
Category HCC short name Diabetes HCC 17 HCC 18 HCC 19 Vascular HCC 106 HCC 107 HCC 108 HCC 161 HCC 189 For these HCCs, Description drop the listed HCCs
18, 19 Diabetes with acute complications 19 Diabetes with chronic complications Diabetes without complication Community 107, 108, 161, 189 108 1.413 Atherosclerosis of the extremities with ulceration or gangrene Vascular disease with complications Vascular disease Chronic ulcer of skin, except pressure Amputation status, lower limb/amputation complications 0.368 0.368 0.118 0.410 0.299 0.536 0.779 21
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Example: Diabetes HCCs & Hierarchy
HCC 17 (0.368)
Diabetes with acute complications
HCC 18 (0.368)
Diabetes with chronic complications
HCC 19 (0.118)
Diabetes without complication
HCC 17
HCC 18
DM (1 or 2 or induced) with DM (1 or 2 or induced) with: • Nephropathy; CKD; other kidney complication; • Coma or retinopathy; cataract; neuropathy; other neuro • Hyperosmolarity or complication; peripheral angiopathy; • Ketoacidosis
neuropathic arthropathy; dermatitis; ulcer; periodontal disease; hyperglycemia; hypoglycemia without coma
HCC 19
DM
22
Detail of HCC 19
HCC 19 (0.118)
Diabetes without complication
Diagnosis code
E089
E099
E109
E119
E139
Z794
Description
Diabetes mellitus due to underlying condition without complications
Drug or chemical induced diabetes mellitus without complications
Type 1 diabetes mellitus without complications
Type 2 diabetes mellitus without complications
Other specified diabetes mellitus without complications
Long‐term (current) use of insulin
CMS‐HCC model category V22
19
19
19
19
19
19
23
Example: Cardiac HCCs & Hierarchy
HCC 86 (0.275) Acute myocardial infarction
HCC 87 (0.258) Unstable angina and other acute ischemic heart disease
HCC 88 (0.141) Angina pectoris
HCC 86
• STEMI or NSTEMI
• Subsequent STEMI or NSTEMI
• Chordae tendinea or papillary muscle rupture (current complication following AMI or NEC)
HCC 87
HCC 88
• USA (with OR without identified atherosclerotic heart • Angina pectoris, disease of vessels or grafts)
unspecified (as well as • Current complications following AMI: Hemopericardium; specified atherosclerotic Atrial or ventricular septal defects; Thrombosis of atrium, heart disease; as well as auricular appendage and ventricle; with spasm)
• Acute ischemic heart disease
• Postinfarction angina; Dressler’s syndrome
HCC 85: Congestive heart failure (0.368)
HCC 96: Specified heart arrhythmias (0.295)
• Multiple: Cardiomyopathies; HF; PE
• Pulmonary hypertension
•
•
•
•
Complete AV block
SVT, VT, re‐entry ventricular arrhythmia
A‐fib or A‐flutter (unspecified or specified)
Sick sinus syndrome
24
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Example: Neoplasm HCCs & Hierarchy
HCC 8 (2.484)
Metastatic cancer and acute leukemia HCC 9 (0.973)
Lung and other severe cancers HCC 10 (0.672)
Lymphoma and other cancers HCC 11 (0.317)
Colorectal, bladder, and other cancers HCC 12 (0.154)
Breast, prostate, and other cancers and tumors 25
Example: Neoplasm HCCs & Hierarchy
HCC 8: Metastatic cancer and acute leukemia
• (almost) Any metastatic site
• Disseminated malignant neoplasm unspecified
• Various ACUTE leukemias
HCC 9: Lung and other severe cancers
HCC 10: Lymphoma and other cancers
Esophagus, stomach, small intestine
Meckel’s diverticulum malignant
Liver, bile duct, gall bladder, pancreas
Trachea, lung
Mesothelioma, unspec & sites
Multiple myeloma
Chronic leukemias
Myeloid sarcoma & leukemia
Monocytic or mast cell or other specified leukemias
• KS
•
•
•
•
•
•
•
•
•
HCC 11: Colorectal, bladder, and other HCC 12: Breast, prostate, and cancers
• Head & neck structures
(oral structures; pharynx, oropharynx, nasopharynx; larynx & associated; ear, nasal, sinuses)
• Additional GI
(large bowel structures including anus; spleen; UNSPECIFIED
intestinal tract)
• Heart & mediastinum
• UNSPECIFIED parts of upper respiratory tract
• Female genital organs (NOT uterus)
• Urinary organs—kidney, bladder, etc.
• Various neoplasms not included elsewhere
(includes 114 codes)
• Metastatic dz of UNSPECIFIED lymph node; axilla & upper limb nodes; skin, breast, genital organs
• Malignant immunoproliferative dz
• Plasmacytoma
• Leukemias:
Chronic lymphocytic; prolymphocytic, hairy cell, lymphoid, Burket, UNSPECIFIED
other cancers and tumors
•
•
•
•
•
•
Melanoma sites
Merkel cell carcinoma
Breast & structures
Uterus
Male genital organs
Eye structures
26
Example: Vascular
HCC 106 (1.413)
Atherosclerosis of the extremities with ulceration or gangrene
HCC 107 (0.410)
Vascular disease with complications HCC 108 (0.299)
Vascular disease
HCC 161 (0.536)
Chronic ulcer of skin, except pressure
HCC 189 (0.779)
Amputation status, lower limb/amputation complications
27
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CMS HCC Version 21 Development
• CMS HCC disease interactions
– The presence of specific combinations of HCCs provides a “bonus” weight, which is in ADDITION to the existing HCC weights
– These disease interactions are presented in detail over the next 4 slides
28
Disease Interactions (Community Based)
•
•
•
•
•
CANCER_IMMUNE Cancer*Immune Disorders 0.947
•
CHF_COPD Congestive Heart Failure*Chronic Obstructive Pulmonary Disease 0.259
•
CHF_RENAL Congestive Heart Failure*Renal Disease 0.317
•
•
COPD_CARD_ RESP_FAIL Chronic Obstructive Pulmonary Disease*Cardiorespiratory Failure 0.456
•
•
DIABETES_CHF Diabetes*Congestive Heart Failure 0.182
•
SEPSIS_CARD_RESP_FAIL Sepsis*Cardiorespiratory Failure 0.214
•
•
Sepsis = HCC 2 Cancer = HCCs 8–12 Diabetes = HCCs 17–19 Immune Disorders = HCC 47 Cardiorespiratory Failure = HCCs 82–84 Congestive Heart Failure = HCC 85 Chronic Obstructive Pulmonary Disease = HCCs 110–111 Renal Disease = HCCs 134–137 29
Disease Interactions (Institutional Based)
•
•
•
•
•
•
•
•
•
•
•
•
CHF_COPD Congestive Heart Failure*Chronic Obstructive Pulmonary Disease 0.221
COPD_CARD_RESP_FAIL Chronic Obstructive Pulmonary Disease*Cardiorespiratory Failure 0.506
DIABETES _CHF Diabetes*Congestive Heart Failure 0.189
ARTIF_OPENINGS_PRESSURE_ULCER Artificial Openings for Feeding or Elimination*Pressure Ulcer 0.282
ASP_SPEC_BACT_PNEUM_PRES_ULCER Aspiration and Specified Bacterial Pneumonias*Pressure Ulcer 0.495
COPD_ASP_SPEC_BACT_PNEUM Chronic Obstructive Pulmonary Disease*Aspiration and Specified Bacterial Pneumonias 0.319
SCHIZOPHRENIA_CHF Schizophrenia*Congestive Heart Failure 0.212
SCHIZOPHRENIA_COPD Schizophrenia*Chronic Obstructive Pulmonary Disease 0.389
SCHIZOPHRENIA_SEIZURES Schizophrenia*Seizure Disorders and Convulsions 0.452
SEPSIS_ARTIF_OPENINGS Sepsis*Artificial Openings for Feeding or Elimination 0.553
SEPSIS_ASP_SPEC_BACT_PNEUM Sepsis*Aspiration and Specified Bacterial Pneumonias 0.339
SEPSIS_PRESSURE_ULCER Sepsis*Pressure Ulcer 0.522
•
•
•
•
•
•
•
•
•
•
•
Sepsis = HCC 2. Diabetes = HCCs 17–19. Cardiorespiratory Failure = HCCs 82–
84. Congestive Heart Failure = HCC 85. Chronic Obstructive Pulmonary Disease = HCCs 110–111. Schizophrenia = HCC 57. Seizure Disorders and Convulsions = HCC 79. Aspiration and Specified Bacterial Pneumonias = HCC 114. Pressure Ulcer = HCCs 157–158. HCCs 159–160 are no longer included in the pressure ulcer interaction terms. Chronic Ulcer of Skin, except Pressure = HCC 161. Artificial Openings for Feedings or Elimination = HCC 188. 30
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Disabled Interactions
COMMUNITY
• D_HCC5 AND DISABLED_HCC6 Disabled, Opportunistic Infections 0.451
• DISABLED_HCC34 Disabled, Chronic Pancreatitis 0.548
• D_HCC44 AND DISABLED_HCC46 Disabled, Severe Hematological Disorders 1.347
• D_HCC51 AND DISABLED_HCC54 Disabled, Drug/Alcohol Psychosis 0.331
• D_HCC52 AND DISABLED_HCC55 Disabled, Drug/Alcohol Dependence 0.331
• D_HCC107 AND DISABLED_HCC110 Disabled, Cystic Fibrosis 2.415
• DISABLED_HCC176 Disabled, Complications of Specified Implanted Device or Graft 0.503
INSTITUTIONAL
• DISABLED_HCC39 Disabled, Bone/Joint Muscle Infections/Necrosis 0.383
• DISABLED_HCC77 Disabled, Multiple Sclerosis 0.407
• DISABLED_HCC85 Disabled, Congestive Heart Failure 0.441
• DISABLED_HCC161 Disabled, Chronic Ulcer of the Skin, Except Pressure Ulcer 0.430
• DISABLED_PRESSURE_ULCER Disabled, Pressure Ulcer 0.270
31
Current Areas of Application:
HCC Success = Expansion Into Other Applications
•
•
•
ACOs
Physician VBP: Physician services payment in the outpatient setting
Risk adjustment (specifically re‐admits & mortality measures)
32
Initial Application  Current Areas of Application
Medicare risk adjustment (i.e., HCC system) applies to: • ACOs & Medicare Advantage plans
• Hospital Value‐Based Purchasing (FY2016 1.75%)
• 30‐day all‐cause mortality
• AMI, HF, PNA
• Care/cost efficiency
• Readmissions Reduction Program (HRRP) (FY2016 3%)
• AMI, HF, PNA (expanding FY17), COPD, elective knee/hip, CABG (FY17)
• Physician VBP: Physician services payment (outpatient setting)
• Combines quality and risk‐adjusted cost efficiency:
• Starting Jan 2015 100+ providers now ‐2% to +3%
• Starting Jan 2016 10–99 providers now 0% to 3%
• HHS—HCC model for the ACA marketplace
33
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ACO and Medicare Advantage Application of HCCs
• CMS’ goal is to move away from fee‐for‐service models and toward population health • Moving incentives from volume of care and services to efficiency and quality of care and services
34
ACO and Medicare Advantage Application of HCCs
• Relies upon the use of predictive models of cost (risk adjustment)
– Data from this year used to predict the costs for the next year
– Medicare Advantage
• Provides a health plan with prospective payment
• Efficiency yields less expenditures and money is saved
– ACO/MSSP • Use data to estimate the predicted costs
• If quality goals are met, and savings exceed a set threshold, then shared savings are achieved
35
ACO and Medicare Advantage Application of HCCs
How is this done?
• Medicare risk adjustment
– Redistributes payments in favor of those providing care to higher‐
risk populations
– Transfer of funds from low‐risk populations to high‐risk populations
– HCC‐based system
– Based on claims data (diagnosis codes) and demographics
• General formula
CMS rate
Demographic weight
HCC weight
Exp cost/reimburse
ment
36
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Clinical Example of HCC Application and Impact
Documentation from an outpatient encounter
75 y/o female presents for ankle sprain and follow‐up
Assessment and plan:
• Ankle sprain—ice avoid NSAIDs due to CKD. Check BMP.
• Colon cancer—s/p colectomy and liver bx. Following with heme/onc for chemo. Check CBC, LFTs.
• Type 2 DM—insulin adjusted.
• CAD—CP at rest, cardiology eval, increase beta blocker.
• Hypertension—continue current meds.
37
Diagnoses on the Claim
Submitted by provider
C189 Malignant neoplasm of colon
E119 Type 2 DM
N189 CKD
I208 Angina
S93402A Ankle sprain
38
HCC Weights Applied to MD Claim Dx
Factor/diagnosis
HCC
HCC weight
75‐year‐old female
Demographics
0.437
C189 Malignant neoplasm of colon
11—Colorectal bladder and other cancers
0.317
E119 Type 2 DM 19—Diabetes without complication
0.118
N189 CKD
‐‐‐
I208 Angina
88—Angina pectoris
S93402A Ankle sprain
‐‐‐
0
0.141
0
Total risk
1.013
Expected cost/reimbursement
$7,200
39
©2016 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without express written permission.
Improvement in Documentation
Documentation from an outpatient encounter
75 y/o female presents for ankle sprain and follow‐up
Assessment and plan:
• Ankle sprain—acute, ice avoid NSAIDs due to CKD. Check BMP.
• Colon cancer with liver mets—active, s/p colectomy and liver bx. Following with heme/onc for chemo. Check CBC, LFTs.
• Type 2 DM with diabetic CKD 4—stable, insulin adjusted.
• CAD—unstable angina, active, cards referral, increase beta blocker.
• Hypertension—stable, continue current meds.
40
Improved Codes
New diagnoses
HCC
HCC weight
75‐year‐old female
Demographics
0.437
C189 Malignant neoplasm of colon
11—Colorectal bladder and other cancers
0.317
C787 Secondary neoplasm of liver
8—Metastatic cancer and acute leukemia
2.484
18—Diabetes with E1122 Type 2 DM with diabetic CKD
chronic complication
0.368
N184 CKD 4
137—CKD severe stage 4
0.224
I200 Unstable angina
87—Unstable angina and
other acute isch hrt dz
0.258
S93402A Ankle sprain
‐‐‐
0
41
Applying the Hierarchies
HCC 12
• Breast, Prostate, and other cancers and tumors
0.154
HCC 11
• Colorectal, bladder, and other cancers
0.317
HCC 10
• Lymphoma and other cancers
0.672
HCC 9
0.973
HCC 8
• Lung and other cancers
• Metastatic cancer and acute leukemia
2.484
42
©2016 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without express written permission.
Revised HCC Weights
New diagnoses
HCC
HCC weight
75‐year‐old female
Demographics
0.437
C189 Malignant neoplasm of colon
11—Colorectal bladder and other cancers
xxxx
C787 Secondary neoplasm of liver
8—Metastatic cancer and acute leukemia
2.484
E1122 Type 2 DM with diabetic CKD
18—Diabetes with chronic complication
0.368
N184 CKD 4
137—CKD severe stage 4
0.224
I200 Unstable angina
87—Unstable angina and
other acute isch hrt dz
0.258
S93402A Ankle sprain
‐‐‐
0
Total risk
3.771
Expected cost/reimbursement
$26,379
43
HCC Expansion
Risk adjustment (specifically re‐admits & mortality measures)
44
CMS Mortality & Readmission Risk Adjustment Overview
• Model unique for each mortality or readmission condition, though similar pattern
• Certain Condition Categories are included in the risk adjustment calculation – (NOT hierarchical)
• 12‐month look‐back for diagnosis (from index admit)
• Certain diagnosis if occurring only during the index admission are excluded—as likely complications of that index admission
• FY15 baseline data includes index admissions
– July 2011 to June 2014
– Both CMS and VA (VA for AMI, HF & PNA) administrative data sources
45
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Example: HF Readmission Cohort Criteria
Inclusion criteria for HF measure • Principal discharge diagnosis of HF •
•
Enrolled in Medicare FFS or are VA beneficiaries – Rationale: Claims data are consistently available only for Medicare FFS and VA beneficiaries. •
•
Age 65 or over – Rationale: Medicare patients younger than 65 usually qualify for the program due to severe disability. They are not included in the measure because they are considered to be too clinically distinct from Medicare patients 65 and over. •
Not transferred to another acute care facility – Rationale: Readmission is attributed to the hospital that discharged the patient to the non‐acute care setting. Transferred patients are still included in the measure cohort, but the initial admitting hospital is not accountable for the outcome. – Rationale: HF is the condition targeted for measurement (Table D.2.1). Enrolled in Part A and Part B Medicare for the 12 months prior to the date of admission, and enrolled in Part A during the index admission – Rationale: The 12‐month prior enrollment criterion ensures that patients were Medicare FFS beneficiaries and that their comorbidities are captured from claims for risk adjustment. Medicare Part A is required at the time of admission to ensure no Medicare Advantage patients are included in the measure. This requirement is dropped for patients with an index admission within a VA hospital. Discharged alive from a non‐federal acute care hospital or VA hospital – Rationale: Patients who are alive are eligible for a readmission. 46
Example: HF Readmission Cohort Criteria
Exclusion criteria for HF measure • Without at least 30 days of post‐discharge enrollment in FFS Medicare – Rationale: The 30‐day readmission outcome cannot be assessed in this group since claims data are used to determine whether a patient was readmitted • Discharged against medical advice (AMA) – Rationale: Providers did not have the opportunity to deliver full care and prepare the patient for discharge 47
Example: HF Readmission Risk Variables (2015)
•
CC 67–69, 100–102, 177–178 paralysis, functional disability •
•
CC 79 CC 80 Cardiorespiratory failure or shock Congestive heart failure Hemiplegia, paraplegia, •
CC 81–82 Acute coronary syndrome •
•
Variable n/a Description Age minus 65 (years above 65, continuous) •
n/a Male •
ICD‐9 codes V45.81, 36.10–36.16 History of coronary artery bypass graft (CABG) •
CC 7 Metastatic cancer or acute leukemia •
CC 83–84 Coronary atherosclerosis or angina •
CC 8–12 Cancer •
CC 86 Valvular or rheumatic heart disease •
CC 15–20, 119–120 complications •
CC 92–93 Specified arrhythmias and other heart rhythm disorders •
CC 21 Protein‐calorie malnutrition •
CC 94 Other or unspecified heart disease •
CC 22–23 Disorders of fluid/electrolyte/acid‐base •
CC 95–96 Stroke •
CC 25–30 Liver or biliary disease •
CC 104–106 Vascular or circulatory disease •
CC 34 Peptic ulcer, hemorrhage, other specified gastrointestinal disorders •
CC 108 (COPD) Chronic obstructive pulmonary disease •
•
CC 36 CC 44 •
CC 109 disorders Fibrosis of lung or other chronic lung •
CC 47 Iron deficiency or other unspecified anemias and blood disease •
•
CC 110 CC 111–113 Asthma Pneumonia •
CC 49–50 Dementia or other specified brain disorders •
CC 129–130 End‐stage renal disease or dialysis •
CC 51–53 Drug/alcohol abuse/dependence/psychosis •
CC 131 •
CC 54–56 Major psychiatric disorders •
CC 132 Nephritis •
CC 58 Depression •
CC 136 Other urinary tract disorders •
CC 60 Other psychiatric disorders •
CC 148–149 Decubitus ulcer or chronic skin ulcer Diabetes mellitus (DM) or DM Other gastrointestinal disorders Severe hematological disorders Renal failure 48
©2016 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without express written permission.
Example: HF Readmission Risk Variables EXCLUDED (2015)
•
•
•
•
•
•
•
•
•
•
•
•
•
Variable Description CC 17 Diabetes with acute complications CC 23 Disorders of fluid/electrolyte/acid‐
base CC 28 Acute liver failure/disease CC 34
Peptic ulcer, hemorrhage, other specified gastrointestinal disorders CC 79 Cardiorespiratory failure and shock
CC 80 Congestive heart failure CC 81 Acute myocardial infarction CC 82 Other acute/subacute forms of ischemic heart disease CC 92 Specified heart arrhythmias CC 93 Other heart rhythm and conduction disorders CC 95 Cerebral hemorrhage CC 96 Ischemic or unspecified stroke Excluded from risk adjustment if ONLY occurrence of the dx is from the index admission
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
CC 100 Hemiplegia/hemiparesis CC 101 Diplegia (upper), monoplegia, and other paralytic syndromes CC 102 Speech, language, cognitive, perceptual CC 104 Vascular disease with complications CC 105 Vascular disease CC 106 Other circulatory disease CC 111 Aspiration and specified bacterial pneumonias CC 112 Pneumococcal pneumonia, emphysema, lung abscess CC 129 End‐stage renal disease CC 130 Dialysis status CC 131 Renal failure CC 132 Nephritis CC 148 Decubitus ulcer of skin CC 177 Amputation status, lower limb/amputation
CC 178 Amputation status, upper limb 49
Operational Considerations: HCCs
• CDI workflows
• CDI concepts
• Application of CDI resources
50
Traditional CDI & HCCs
• Natural component of the CDI approach to focus:
– Completeness and accuracy without regard to financial or other focused concerns – This approach attempts to capture all relevant codes to the highest levels of specificity – Naturally leads to better HCC capture and profiles
51
©2016 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without express written permission.
Traditional CDI & HCCs: MUSIC
MUSIC (Dr. James Kennedy)
• Manifestation
– Chest pain
• Underlying cause or pathology
– Angina, GERD, CAD, coronary spasm, complication of stent, etc.
• Severity or Specificity
– Stable or unstable angina, AMI
• Instigating or precipitating cause
– Cocaine abuse, trauma, anemia, etc.
• Complications or Consequences
– Shock, acute systolic heart failure, ventricular tachycardia, etc.
• Place a diagnosis existing in the medical record into the appropriate category, then look for the other four
– Either documented or clinically indicated
– Obtain the appropriate linkages needed (due to, resulting, etc.)
52
Operational Areas of Focus
• Inpatient:
– Improving perceived readmission, mortality, and cost‐
efficiency measures by impacting the EXPECTED side of these measures
• Outpatient:
– Physician payments
• ACO—combined inpatient and outpatient areas
53
Operational Areas of Focus
Inpatient setting
• Existing CDI programs
– Layer HCC into existing
• Professional coding staff
• Identify areas of primary focus – Subset • (Specific readmit or mortality measures)
– All HCC categories in play
• Cost‐efficiency measure
• Support partner/related ACO
• Leverage with MA plans
Outpatient setting
• Rare CDI existing program
• Often no professional coding (physicians report codes)
• Most patients do not have acute inpatient stay
• Much larger volume
• Leverage processes of care
• Possible key resource—
existing MA contractor
• Focus:
– All HCCs in play
• Availability of software/EHR/data analytics tools
• Education and knowledge to providers VS. chart review
54
©2016 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without express written permission.
Traditional CDI & HCCs
• Conceptual low‐hanging fruit:
–
–
–
–
Commonly missed HCC Dxs
CMS HCC disease interactions
Linkage (due to)
Move up the hierarchy
• Diagnosis NOT INCLUDED:
–
–
–
–
Documentation present but not billed
Clinical evidence without documentation
Absence of chronic conditions in documentation
Self‐imposed limits on # of codes reported
• Related diagnosis
– COPD/CHF/O2 use: Chronic respiratory failure
– cancer/dementia: malnutrition
55
Operational Considerations: CDI Applied to ACO and MA Models
• Fundamental concepts
• Opportunity analysis
• Strategic application
56
Before We Start …
Fundamental concepts to set the stage
• HCC score (MRA) is reset to 0 each year
– Diagnoses must be resubmitted on ANY claim at least once EACH year
• Amputations grow back
• All diseases cured
• ACO HCC scores may be locked in for a 3‐year cycle
– They can decrease annually
– They do not increase annually
• Newly attributed patients (new to Medicare) need to establish an HCC score
57
©2016 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without express written permission.
Before We Start …
Fundamental concepts to set the stage
• Concepts for reportability, documentation, and coding still apply –
–
–
–
MEAT (monitored, evaluated, assessed, treated)
Face‐to‐face encounter
Condition on claim must match the documentation
Each diagnosis should have an assessment and plan
• Documentation:
– Legible, physician signature & credential, dated
– Condition status, labs, exam, symptoms, education, plan
– Code ALL conditions that affect the patient’s care at time of visit
• Common CDI principles & concerns apply
• ASSUME CMS will audit
58
How Do You Apply a Limited Resource to a Large Problem?
Find high‐opportunity targets and issues
• Frequency of unspecified codes
• Patient volumes and HCC score per provider
• Identify high‐volume users of unspecified codes (e.g., diabetes)
• Cost of care and HCC score per provider
• New providers—start them on the right track
• Patients with no HCC score (other than demographics)
• Unmanaged patients
• ?? use of registries, benchmarked dx capture
59
How Do You Apply a Limited Resource to a Large Problem?
Timing for “capture” opportunities
• Newly attributed patients
– Build the HCC score
• Annual wellness visits
–
–
–
–
Reaffirm old diagnoses
Establish new diagnoses
Clarify disease interactions and relationships
Specify unspecified
60
©2016 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without express written permission.
Leverage Your Assets With CDI Knowledge
Tools to use
• EHR
– BPAs
• DM and related conditions
• CKD staging
• Obesity, other diagnoses
– Diagnosis picker/calculator
• Help get to specified codes
• Assist providers to get required details and complications/manifestations
– Problem list and templates
• Ensure documentation and claims data match
• GET RID OF “HISTORY OF”
61
Use Your Staff Wisely
Where can CDI directly impact OP?
It’s impossible to review all visits for all patients.
• Prescreen annual wellness visits
– Look for HCC opportunities
– Pre‐populate the documentation issues for the provider
– Continuous workload (as opposed to end‐of‐year blitz)
• Work with OP coding/audit team (if you have one)
– Examine audit results (missing dx, unsupported dx, unspecified dx)
– Train the audit team to look for opportunities for feedback to the providers
• Train annual wellness visit nurses
• Train physicians and providers
62
Use Your Staff Wisely
How can we utilize existing CDI processes?
A portion of your ACO/MA patients will be seen for inpatient care.
• Add areas of HCC knowledge and focus for your inpatient CDI staff
– DM and manifestations
– Secondary sites of cancer
– Comorbid conditions (PVD, COPD, angina, etc.)
63
©2016 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without express written permission.
Modes of Communication
How can/should CDI staff spread the word?
• Documentation tips
– Hit the hot topics/low‐hanging fruit
• Office visits
– Lunch and learns
– Staff meetings
– Annual wellness training
• New provider training
– Hit the highlights for good documentation and coding
• Collect and use case examples
– Audit results (internal or external)
• Video training
– Saves time and repetition
– Can be accessed anytime
64
Summary
65
Summary
• RISK ADJUSTMENT methodologies are widespread
• Dig into literature review and associated web pages
• Provider education (repeated, focused, motivate)
– Use data analysis to prioritize initial & focus
• Understand & leverage hierarchy structure
• Time frame RESETS
• Leverage existing data, tools, & processes of care
– BPAs, EHR, Dx picker/calculator, etc.
• Process of care—annual wellness visits
66
©2016 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without express written permission.
Summary: Diagnostic Low‐Hanging Fruit
•
•
•
•
Morbid obesity
Malnutrition
CKD staging (4 or 5)
Complications of care
–
–
–
–
–
Mechanical problems
Prosthetic devices
Infections
Implants
Grafts
• PVD/claudication
• Diabetes manifestations
• Afib, PSVT
Cirrhosis (due to …)
Transplant status
Artificial openings
Amputation status
Late effects of CVAs
Status of MIs Neoplasms and metastatic cancers
• ESRD and the need for dialysis (HD or PD)
• Major depression, etc.
•
•
•
•
•
•
•
67
Summary: Broad Strategies
• Diagnosis capture
– Moving up within a hierarchy
• Cancer, diabetes, cardiac
– Related Condition Category • Commonly coexisting diagnosis to capture
– Increasing specificity of existing diagnosis
– Complete capture of ALL conditions • Monitored, evaluated, assessed, treated
– Supportive documentation present for reported codes
• Additionally worth focus
– Vascular/PVD; skin/ulcer; end‐stage liver dz; spinal
• Review and understand ALL of the hierarchies
68
Thank you. Questions?
dbutler@vidanthealth.com
vaughn.matacale@vidanthealth.com
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 program guide. 69
©2016 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without express written permission.