Outpatient CDI
Implementation, Integration,
and Issues
NYHIMA 79th Annual Conference
Tuesday, June 3, 2014
Mel Tully MSN, CCDS, CDIP
NOT SURE
ANOTHER DAY
SOMEDAY
ICD-10 Will Launch
NEVER
NEXT YEAR
PERHAPS
Key Discussion Points
• Current state of Outpatient CDI Programs
• Background and structure of Medicare
Advantage (MA) program
• CMS Hierarchical Condition Categories
(HCCs) and HCC model
• Integration of current inpatient CDI and
outpatient CDI
• CDI role in outpatient denials
• Education for clinical documentation
specialists, coders, and providers
Current State - Outpatient CDI
Program
•
Hospital Outpatient
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Most hospitals have implemented inpatient CDI programs, outpatient CDI has not been
a focus
•
•
•
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Outpatient volumes are very high and hospitals cannot afford to staff CDI programs in
these areas
Hospitals focus on Revenue Integrity functions
•
•
Likely because hospitals are financially strapped,
Have many competing priorities,
Little to no data available on the success of outpatient CDI
Medical Necessity Audits and Charge Master/Charge Capture through Revenue Integrity
Specialists with a non-clinical focus
Physician Office
–
–
Physicians are reimbursed based on E/M and CPT codes and do not have a good
understanding of how critical clinical documentation can be to preventing denials.
E/M Auditing is a high demand services. Most physicians, whether owned or
independent have an external vendor perform an annual E/M Audit as part of their
Compliance Plan. However, physicians are very price sensitive for this service.
Physician Engagement for
OP-CDI
• Accurate clinical documentation is essential for quality patient
care.
• Over recent years, based largely on the MS-DRG system,
physicians have become aware of the impact of accurate and
complete clinical documentation on physician profiles, morbidity
and mortality data, and hospital reimbursement.
• With the rapid industry transition to quality-based payment,
physicians have an even greater incentive to understand and
assure accurate documentation.
• Many physicians are now receiving financial incentives under
Medicare Advantage programs. Few understand the revenue
impact of complete and accurate documentation in all clinical
settings.
• With the advent of ACOs and other integration models,
physicians are increasingly accepting financial risk associated
with patient management.
MEDICARE ADVANTAGE AND
CMS HIERARCHICAL CONDITION
CATEGORIES
Medicare Advantage (MA) (Part C)
Medicare Risk Adjustment
• Type of Medicare health plan
– Contracts with CMS to provide benefits
– Purpose of the CMS-HCC model is to promote fair payments
to MA plans that reward efficiency and encourage high
quality care for the chronically ill.
• Part A and B, and oftentimes including Part D (RxHCC)
– Extra dental, vision, hearing and preventive services
– Some optional services such as exercise classes
• Plan receives payment for each member from CMS
– Payment based on member predicted health status and
demographic characteristics
• 2013 enrollment – 14.4 M (28%)
– Up nearly 10% since 2012
HCCs
• HCC concept similar to DRGs
• Each member (patient) has Risk Adjustment Factor (RAF)
score
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–
–
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Organization average RAF score similar to case mix
Score of 1 represents typical patient
Less than 1 is healthy patient
Greater than 1 likely patient utilizes greater resources
• Certain diagnoses/status increase RAF
– Similar to CCs and MCCs (75% are classified as CCs/MCCs)
– Usually chronic conditions—but not always
– Specific documentation & coding increases the mapping
likelihood
• Reported for certain encounters based on setting &
provider type
HCC Uses
• Medicare Advantage Capitation Payment
• Shared Savings Program
– Accountable Care Organizations
• Historical benchmark expenditures adjusted
based on CMS-HCC model
• Medicare Physician Quality and
Resource Use Reports
• Value Based Purchasing Initiatives
(Bundled Payments)
Risk Adjustment Status
• Currently payers receive most benefit
• Some physicians incentivized, especially in CA
• ACA is changing environment, increasing
provider stake
– Accountable Care Organizations
– Patient Centered Medical Homes
• Many current vendors focus on home visits to
members because insufficient OP
documentation
• MA plan enrollment increasing
HCCs/Multiple Chronic
Diseases
Base
payment for each member based
on HCCs and influenced by
Medicare Costs for Chronic
Diseases
Diagnostic Sources
Disease Interactions
CMS Will Only Consider
Diagnoses from IP & OP
Hospital & Physician Data
Additional factors applied when
hierarchy of more severe and less
severe conditions co-exists
Prospective in Nature
Diagnosis from base year used to
predict payments of next year
• New Enrollee vs Existing Enrollee
Demographics
Characteristics of
CMS-HCC Model
Final adjustment due to: age,
sex, original Medicare
entitlement, disability &
Medicaid status
Key Analytics for HCC Capture
Where is HCC data collected?
• Medicare claims and encounter data
• Early intervention to ensure quality clinical outcomes – HCC
CDS
• Retrospective and prospective reviews including chart
audits
• Health status assessment each year – ‘Patient Summary
Visit’
–
–
–
–
Monitored
Evaluated
Assessed
Treated
• Quarterly review of members to assess patient data
– Health status above/below 1
– Jumps in RAF scores
Diagnosis Sources—
Provider Types
• Diagnoses documented by select provider types are
appropriate for coding and reporting for MA coding.
• MD or DO
–
–
–
–
–
OD
DC
DDS
DO
DPM
Doctor of Optometry
Doctor of Chiropractor
Doctor of Dental Surgery
Doctor of Osteopathy
Doctor of Podiatry
• All NP, CNS, PA
• Therapists—except “respiratory”
• LCSW/CSW Licensed Clinical Social Worker/Clinical Social
Worker
• CWCN/CWOCN Certified Wound Care/ostomy Nurse
Disease Hierarchies
• Address situations when:
– Multiple levels of severity for a disease or
clinically related
• Payment based only on most severe and costly
manifestation of disease
– Varying levels of associated costs
…..are reported for the same patient
• Hierarchies are published in the Rate
Announcement
Figure 2-3
Clinical vignette for
CMS-HCC (version
12) classification
community-residing,
76-year-old woman
with AMI, angina
pectoris, COPD, renal
failure, chest pain, and
ankle sprain
Hierarchical Condition Categories
Rules
• Although HCCs reflect hierarchies among
related disease categories, for unrelated
diseases, HCCs accumulate
– For example, a male with heart disease, stroke,
and cancer has (at least) three separate HCCs
coded, and his predicted cost will reflect
increments for all three problems.
– So unlike DRGs, there may be several HCCs
assigned to an individual
Breakdown of HCC
• 3033 ICD-9 codes are mapped to 87 categories
(11,312 ICD-10 CM codes)
• HCC logic is imposed on certain disease groups
• The HCC model is cumulative, so that a patient
can have multiple diagnoses assigned
• Each diagnosis is factored into the member’s risk
profile which calculates an individual RAF score
(Risk Assessment Profile)
• RAF score = “ambulatory CMI” and is calculated
annually
Hierarchical Condition Categories (HCC)
Why you should get to know them now
• The Medicare risk adjustment payment
system uses clinical coding information
to calculate risk premiums for Medicare
Managed Care Organizations
• HCC payments are linked to the
individual health risk profiles for each
member in the plan
• HCC codes are captured through
accurate physician documentation
Here’s How the System Works
• If the average risk score for the overall population is
defined as 1.0, a healthy young man might receive a score
of 0.4 based on historical claims data, while a young
woman with asthma might be scored at 1.5, and an older
person with diabetes might be scored at 2.3.
• A plan having an aggregate score of 1.2 for its enrollees
would receive a 20 percent add-on to its average per
person payments, while a plan with an aggregate score of
0.8 would experience a 20 percent reduction in payments.
• In practice, individual risk scores, built from data on patient
demographics, disability, institutional status, and
diagnoses, are used to help determine monthly payments
made to plans for each person enrolled in Medicare
Advantage, Medicare Part D prescription drug benefits, and
many state Medicaid managed care programs.
CDI Case Study
Risk Adjustment 101: Case Study
HCC Calculation
Expect Audits to Validate Coding
• Upcoding can undermine risk adjustment if
it distorts the actual health-risk profile of a
plan, for example, by suggesting that the
people that the plan has enrolled are
actually sicker than they really are.
• Expect audit plans to enforce coding
“integrity”—that is, consistent use of
diagnosis codes to negate any effect of
upcoding.
Specificity Opportunities
• Depression vs major depression (type)
• Asthma vs chronic obstructive asthma/emphysema/chronic
bronchitis
• Bronchitis vs chronic bronchitis (acuity/chronicity)
• CAD vs angina/unstable angina (severity)
• Cardiac dysrhythmia vs atrial fibrillation (specificity)
• CVA vs late effect CVA/hemiplegia (current vs late effect)
• Diabetes and PVD vs. Diabetic PVD (cause/effect
relationship)
• Status of cancer is unclear and treatment is not
documented
• Chronic conditions not documented once per year
•
Common Documentation
Challenges
Problem Lists
•
•
•
Past Medical History (PMH)
–
•
Current conditions impacting encounter documented here—and no where else in the
documentation
History of diagnoses
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–
•
•
•
•
•
•
•
Not updated
Title (“Active”, “Chronic”, “Concurrent”)
Coding a past condition as active (CVA, CA, AMI)
Coding history of when condition is still active (COPD, CHF)
“History of CHF” on Lasix vs. “Compensated CHF, stable on Lasix”
Medication—but no coordinating diagnosis
Ostomy supplies—but not ostomy diagnosis
Labs and radiology ordered—but no indication of why
Physical exam—but no mention of status amputation
Assessment—but not mention of AAA size or status
Inconsistent documentation
Record indicates depression, NOS but diagnosis code written on encounter document is
major depression
Medical Record Requirements
• Two patient identifiers on each page: Patient’s name and
birth date
• Date of Service (complete and legible)
• Face-to-face encounter with acceptable type provider &
setting
• Condition(s) must be documented—they cannot be
assumed
• Acceptable provider signature, with credential
• Documentation, signature and credentials must be legible
• No copying/pasting/cloning
• Diagnostic test results must be reiterated not copied into
document
Potential Points of Breakdown
• Identification
– Do providers review past medical records?
– Does EHR integrate across all sources?
• Documentation
– If providers are busy, do they record all coexisting conditions?
– Do they record their thought processes?
• Coding
– Are coders coding all documented conditions?
– Are coders aware that 5010 allows up to 12 diagnosis codes?
• Billing
– What are the hand-offs between coding and claims submission?
– Are all coded diagnoses captured on claim?
• Functional
– Do medical records meet stringent HCC requirements?
• Reporting
Risk Adjustment Data Validation Audits
RADV
• National and Targeted Audits
• Enrollees are sampled from selected MA
contracts for the purpose of estimating payment
error related to risk adjustment
• CMS will select up to 201 enrollees for medical
record review from each contract selected for a
contract-level audit
• CMS will calculate each contract’s payment error
based on the validation results
• Results may be extrapolated against total
enrollment
• Payment recovery calculation, if applicable
VBP New Claims-Based Measure
• Medicare Spending per
Beneficiary
• It is important that the
cost of care be explicitly
measured so that, in
conjunction with other
quality measures included
in the Hospital IQR
Program, CMS can
recognize hospitals that
are involved in the
provision of high quality
care at lower cost
CMS Intent
• To measure hospital-specific Medicare spending
per beneficiary, as compared to the median
Medicare spending amount across all hospitals
nationally
• Will best allow hospitals to recognize where
opportunities for improved efficiencies exist
• 3 days prior to hospital admission through 30
days post hospital discharge – Part A & Part B
• Exclude cases involving acute to acute transfers
Medicare Spending Per Beneficiary
• The data for the Medicare spending per
beneficiary measure will be posted on Hospital
Compare
• CMS has finalized this measure for inclusion in
the Hospital VBP Program beginning with the
Fiscal Year (FY) 2015 program year.
• CMS to make adjustments for beneficiary age
and severity of illness (SOI)
– SOI calculated by applying the HCC hierarchical
condition categories which apply to the
beneficiary during the 90 days preceding the
Medicare spending per beneficiary episode
A Strategic Opportunity
• HCCs are assigned using hospital and
physician diagnoses from any of the
following sources:
– Hospital inpatient
• Principal diagnoses
• Secondary diagnoses
If physician documentation is
a limiting factor under MSDRGs, consider the impact
under CMS-HCC
– Hospital outpatient
– Physician, and
– Clinically-trained non-physician (e.g.,
psychologist, podiatrist)
HCC Purpose
• “The ultimate purpose of the CMS-HCC model is
to promote fair payments to MA plans that
reward efficiency and encourage high quality
care for the chronically ill. “
– “CMS is continually conducting research on refining
the CMS-HCC risk adjustment model. A major focus
of this research is the incorporation of variables
that increase the predictive accuracy of the CMSHCC model for high-cost beneficiaries for whom
the model doesn’t fully predict expenditures.”
• Does anyone not think this will be used for ACO
bundled payment?
CMS Finalizes
• Program Changes for Medicare
Advantage and Prescription Drug Benefit
Programs for
Contract Year 2015 (CMS-4159-F)
• Improving payment accuracy: Report
and return identified Medicare
overpayments but cannot submit
diagnosis codes for additional payment
Thinking Outside the Box;
Protect your Ambulatory Documentation
• Traditional CDI programs focus on concurrent
inpatient review of documentation
• Ambulatory records are just as vulnerable to
documentation scrutiny
– Records that lack specific diagnoses will be denied
for payment
– Physicians need feedback on what documentation
must be included for hospitals to get paid
CDI Mitigating Risk:
3rd Party Audits
• Perform CDI review on all cases that are
requested for review
– Appropriate documentation to support coding?
– Assist with Medical Necessity review
• Clinical expertise is critical when defending
against auditors (RAC, OIG, 3rd party coding
audits)
• CDI part of your multidiscplinary team
approach to defend your records
CDI at Work in the Ambulatory Setting
Hospital denied reoccurring chemotherapy charge because only one cancer was
documented
CDI at Work in the Ambulatory Setting
Example: Hospital denied reoccurring chemotherapy charge because only
one cancer was documented
Original denial: $170,000
CDI at Work in the Ambulatory Setting
Example: Hospital denied payment for device based on lack of
documentation by surgeon
Dr. XXX ,
We have a denial from Medicare on a patient that
received a VNS (attached). Medicare needs to have
documentation of either A) a failed surgery prior to the
VNS or B) documentation that the patient is not a good
surgical candidate and therefore needs the VNS.
Based on my review, this patient is quite complex and
would like your opinion if he falls into the “B” category.
Would you please review and if you agree, amend your
note to include that phrase? If this patient does not
meet A or B, please let me know and we will accept
the denial of this surgery.
CDI at Work in the Ambulatory Setting
Example: Hospital denied payment for device based on lack of
documentation by surgeon
Dr. XXX ,
We have a denial from Medicare on a patient that
received a VNS (attached). Medicare needs to have
documentation of either A) a failed surgery prior to the
VNS or B) documentation that the patient is not a good
surgical candidate and therefore needs the VNS.
Based on my review, this patient is quite complex and
would like your opinion if he falls into the “B” category.
Would you please review and if you agree, amend your
note to include that phrase? If this patient does not
meet A or B, please let me know and we will accept
the denial of this surgery.
Original denial: $150,000
Formalize Your Denial Process
Best Practice:
1. Ensure you
have the right
people at the
table
2. Track results
3. Meet monthly
to review
progress
SOLUTIONS AND NEXT STEPS
Assessment
Education HCC CDI
Implementation
A Strategic Opportunity
• HCCs are assigned using hospital and
physician diagnoses from any of the
following sources:
– Hospital inpatient
• Principal diagnoses
• Secondary diagnoses
If physician documentation is
a limiting factor under MSDRGs, consider the impact
under CMS-HCC
– Hospital outpatient
– Physician, and
– Clinically-trained non-physician (e.g.,
psychologist, podiatrist)
HCC CDI Program Benefits
• Complete and accurate ICD-9 coding
• Integration of ICD-10 training to assure a smooth
transition on 10/01/your guess is as good as mine,
• Appropriate coexisting condition identification that
meet criteria for monitoring, evaluation,
assessment, or treatment;
• Physician support of improved documentation ;
• Risk Adjustment Factor alignment with patient
acuity and severity;
• Accurate claims submission to reduce administrative
costs associated with errors; and
• Increased readiness for dealing with potential RADV
(Risk Adjustment Data Evaluation) audit(s)
Moving Forward
• Education, analytics and workflow solution addressing
the challenges of outpatient CDI and HCC coding
requirements
• Extend the current CDI workflow to support a
centralized model of concurrent review of suspect
HCC
• Capture pre-billing by leveraging the Systems CDS
department and your investment in best practices and
tools
• Improve revenue capture for Medicare Advantage
Plan, Value-Based-Purchasing, and ACO initiatives
Summary
• “The ultimate purpose of the CMS-HCC model is
to promote fair payments to MA plans that
reward efficiency and encourage high quality
care for the chronically ill. “
– “CMS is continually conducting research on refining
the CMS-HCC risk adjustment model. A major focus
of this research is the incorporation of variables
that increase the predictive accuracy of the CMSHCC model for high-cost beneficiaries for whom
the model doesn’t fully predict expenditures.”
• Does anyone not think this will be used for ACO
bundled payment?
Thank You!
Questions: mel.tully@jathomas.com
Copy of Presentation: doug.shaddick@jathomas.com