Transcript 252208

3rd Annual
Association of Clinical
Documentation
Improvement
Specialists Conference
Inpatient Medicare
Advantage: HCC Capture
Through CDI
Gloryanne Bryant, BS, RHIA, RHIT, CCS, CCDS
Regional Managing Director of HIM
NCAL Revenue Cycle
Kaiser Foundation and Hospitals
Goals/objectives
• Provide an Overview of Hierarchical
Condition Categories (HCC) and payment
methodology
• Learn the Similarities and Differences
between MS-DRGs and HCCs
• Understand the Documentation and
Coding issues
• Learn how to Incorporate MA into your
CDI program and processes
A little Medicare quiz
#1 There are four types of Medicare
coverage
•
True or False?
#2 Medicare Advantage is also referred to
as Medicare Risk, Medicare C, Medicare
Managed Care
•
True or False?
A little Medicare quiz
#3 How many citizens were enrolled in
Medicare in 2009?
•
35 million, or 45 million, or 50 million, or 55 million
#4 Medicare headquarters are in
Washington, DC. True or False?
#5 Of all Federal Government expenditures,
Medicare is in the top 3. True or False?
Medicare beneficiaries &
chronic conditions
Medicare
• There are several types of Medicare
Healthcare coverage: Medicare A, Medicare
B, Medicare C, and Medicare D (or Rx plan).
• Medicare Advantage is often referred to as
MA, Medicare C, Medicare Risk, Medicare
Capitation, and Managed Care.
• 2009 it was reported that there were 45
million people on Medicare, with 22% of
these being enrolled in private Medicare
Advantage plan.
Medicare Advantage plan
enrollment 2009
Medicare Advantage enrollment
Medicare Advantage (MA) model
• To ensure a health-based risk assessment system, CMS
monthly capitated payments need to take into
consideration the severity of illness of the patient.
• Diagnosis information is collected for each patient which
will determine the payment for the following year.
• The intended goal is to pay Health plans appropriately
for the relative risk of their patients.
• Promote fair payments and reward organizations for
efficiency and excellent care for the chronically ill.
What is Risk Adjustment?
• Medicare Advantage adjusts their monthly
per capita payments to Health Plans to take
into account the relative health of their
members; “Risk Adjustment.”
• Health Plans receive less payment for
healthier members/patients and more for
sicker members.
– The relative health or “risk adjustment factor” is
based on diagnoses (coded data) submitted by
the Health Plan in the prior year.
– The “risk” score comes from the weight (assigned
value) of the Hierarchical Condition Categories
(HCC)
7
Reimbursement model from CMS
Under CMS guidelines, providers are reimbursed based on
that patient’s:
• Membership/Patient
– Age
– Sex
– Geographic Area
• Risk for future healthcare costs
• Each calendar year, based on diagnosis identified,
documented, and coded (meeting the definition of a
reportable condition)
How does the model work?
• CMS adjusts Medicare Advantage payments to private
healthcare plans based on health expenditure risk of
enrollees.
• The “CMS-HCC model uses demographics and a
diagnosis-based medical profile captured during all
clinician encounters—both inpatient and outpatient—to
produce a health-based measure of future medical
need.”
–
Medical Care, Vol 43, Number 1, January 2005, pg. 34.
• This methodology is used to calculate payments for
Medicare managed care plans (Medicare Advantage or
Medicare Part C).
Why is this important to know?
• The diagnoses captured predict the future care
expenditures.
• If we document, address, and capture/code
these diagnoses:
– Our patients receive better quality care
– Clinical data represents the severity of our patients
– Providers receive the appropriate reimbursement for
the care we provide
Sources of diagnostic information
•
Diagnosis information is collected from the following
sources (continuum of care for the calendar year):
– Hospital inpatient principal & secondary diagnoses (internal & external)
– Hospital outpatient diagnoses (internal & external)
– Physician diagnoses (internal & external) regardless of setting (e.g.,
could be from hospital rounding, SNF rounding, ICFs, Dialysis Centers,
and home visits)
– Diagnoses made by clinically trained non-physician providers (e.g.,
psychologists, podiatrists, nurse practitioners, physician assistants)
•
Although most Medicare Advantage diagnoses for
HCCs are made in the ambulatory setting, there are
some “specific” HCCs in the inpatient setting with
opportunity.
15
ICD-9-CM and HCCs
HCC list
HCC Category Description
• 1 HIV/AIDS
See Appendix
• 2 Septicemia/Shock
• 5 Opportunistic Infections
• 7 Metastatic Cancer and Acute Leukemia
• 8 Lung Upper Digestive Tract and Other Severe Cancers
• 9 Lymphatic Head and Neck Brain and Other Major Cancers
• 10 Breast Prostate Colorectal and Other Cancers and Tumors
• 15 Diabetes with Renal or Peripheral Circulatory Manifestation
• 16 Diabetes with Neurologic or Other Specified Manifestation
• 17 Diabetes with Acute Complications
• 18 Diabetes with Ophthalmologic or Unspecified Manifestation
• 19 Diabetes without Complication
• 21 Protein-Calorie Malnutrition
• 25 End-Stage Liver Disease
• 26 Cirrhosis of Liver
• 27 Chronic Hepatitis
• 31 Intestinal Obstruction/Perforation
• 32 Pancreatic Disease
• 33 Inflammatory Bowel Disease
• 37 Bone/Joint/Muscle Infections/Necrosis
• 38 Rheumatoid Arthritis and Inflammatory Connective Tissue Disease
• 44 Severe Hematological Disorders
• 45 Disorders of Immunity51Drug/Alcohol Psychosis
• 52 Drug/Alcohol Dependence54Schizophrenia
• 55 Major Depressive Bipolar and Paranoid Disorders
for Complete List of HCCs
Hierarchical Condition Categories
— related diseases
• Hierarchies are established so that each patient is only
paid for the most severe manifestation among related
diseases.
– For instance, ischemic heart disease diagnoses are organized in
the Coronary Artery Disease (CAD) in the hierarchal category.
• The CAD hierarchy consists of three Hierarchical Condition
Categories (HCC) arranged in descending order by clinical severity
and cost.
– HCC 81 for Acute Myocardial Infarction (AMI) through HCC 83
for Coronary Atherosclerosis/Other Chronic Ischemic Heart
Disease.
– A patient with a diagnosis code in HCC 81 is excluded from the
payment grouping in HCCs 82 and 83, even if these ICD-9-CM
codes are present, as the hierarchy is applied.
18
Disease hierarchies
• 33 of the 70 HCCs are in hierarchies:
– Hierarchy: group of HCCs with same disease at
sequential levels of severity (and costs)
– Example: Diabetes = HCC 15, 16, 17, 18, 19
depending on type of complications
– Purposes:
• Diagnoses are clinically related and ranked by cost
• Takes into account the cost of the lower HCCs reducing the
need for coding proliferation
– Risk factors within a hierarchy are additive; the
highest “trumps” the lower conditions
CMS Model Categories and
Hierarchies (HCCs) — examples
Diabetes
1) Diabetes w/Renal or
Peripheral Circulatory
Manifestation
2) Diabetes w/Neurologic or
Other Specified
Manifestation
3) Diabetes w/Acute
Complications
4) Diabetes
w/Ophthalmologic or
Unspecified
Manifestations
5) Diabetes w/o
Complications
Cancer
1) Metastasis Cancer & Acute
Leukemia
2) Lung, Upper Digestive Tract,
& Other Severe Cancers
3) Lymphatic, Head & Neck,
Brain, & Other Cancers &
Tumors
4) Breast, Prostate, Colorectal &
Other Cancers & Tumors
Kidney Disease
1) Dialysis Status
2) Renal Failure
3) Nephritis
Vascular Disease
1) Vascular Disease
w/Complications
2) Vascular Disease
3) Chronic Ulcer of Skin,
Except pressure
(decubitus)
Hierarchical Condition Categories —
unrelated diseases
• For unrelated diseases, HCCs accumulate.
– For instance, a patient with heart disease, stroke, and cancer will have
three separate HCCs (payments) totaled together for the year.
• The predicted cost will reflect increments for each of these three
HCC categories.
• This model also considers the fact that some diseases interact and
that the predicted cost may be more than the sum of the separate
increments.
– For instance, the presence of both CHF and COPD leads to a higher
cost than the predicted cost for the sum of these conditions. CMS calls
this an “interaction term.”
• To improve clinical validity and predictive accuracy, the interaction
among common and high-cost chronic diseases was considered.
– These include diabetes, cerebrovascular disease, vascular disease,
COPD, CHF, and renal failure.
21
CMS reimbursement is based on the
Hierarchical Condition Categories (HCC)
– Providers are reimbursed based on the most
severe diagnosis within each category.
– Disease categories are accumulated — that
is, reimbursements are based on the sum of
all chronic conditions diagnosed in different
hierarchical categories.
Medicare Advantage HCC annual
payment methodology — example
RISK FACTOR
No Risk
Adjustment
Factor
Atrial
Fibrillation
CHF
DM II W/ Diabetic
CKD, Stage III
$4,000.00
$4,000.00
$4,000.00
$4,000.00
$2,000.00
$2,000.00
$2,000.00
$2,000.00
$7,000.00
$7,000.00
$7,000.00
$4,000.00
$4,000.00
History of
MI
Base payment
Age
$4,000.00
History of MI
Sepsis
CHF
DM II W/
Diabetic CKD,
Stage III
TOTAL ANNUAL
REIMBURSEMENT
$10,000.00
$4,000.00
$6,000.00
$13,000.00
$17,000.00
* Dollar amounts are rounded estimates and do not reflect actual reimbursement rates
$27,000.00
Medicare Advantage HCC annual payment
methodology — example (cont.)
RISK FACTOR
Age
No Chronic
Conditions
Cancer Lung
Metastatic
Bone Cancer
Protein Calorie
Malnutrition
(PCM)
Pressure Ulcer,
Hip
$4,000.00
$4,000.00
$4,000.00
$4,000.00
$22,000.00
$22,000.00
$22,000.00
$8,000.00
$8,000.00
Base
Payment
$4,000.00
Cancer Lung
$10,000.00
Metastasis to
Bone
Protein Calorie
Malnutrition
(PCM)
Pressure Ulcer,
Hip
TOTAL ANNUAL
REIMBURSEMENT
$11,000.00
$4,000.00
$14,000.00
$26,000.00
* Dollar amounts are rounded estimates and do not reflect actual reimbursement rates
$34,000.00
$45,000.00
HCCs that often are seen in the
inpatient setting
Note: a weight of 0.267 would = $2,507 approx reimbursement
Documentation is a focus
• It’s a QUALITY issue:
– All diagnoses considered in the medical
decision-making process need to be documented.
– Explicit documentation makes the diagnosis
apparent to other providers and ensures that
internal and external reporting accurately reflects
the quality of care provided.
• It’s a REIMBURSEMENT issue:
– Appropriate CMS reimbursement is received only
if the diagnoses are documented and coded
appropriately.
Requires greater efficiencies
ICD-9-CM codes selected
• Under Medicare Advantage certain
conditions and/or disease have been
identified to be “higher risk,” higher cost
and resources.
• Annually CMS reviews the list of ICD-9CM codes that are considered to be
conditions that are classified under MA as
“risk.”
• There are similarities to MCC/CCs and
overlap.
ICD-9-CM codes into HCCs
• The selected ICD-9-CM codes are then
“clustered” into categories or hierarchy
condition codes (remind you of grouping of
DRGs)
• For example, HIV/AIDS is within HCC 2 for
ICD-9-CM codes:
ICD-9-CM HCC list
Specific payment for HCCs
• Adjustments are made for HCC payment
– Only for diagnosis NOT procedures
• This is an “ANNUAL” payment and covers
both hospital, outpatient and physician.
• Most conditions/diagnoses appear in the
outpatient physician clinic setting.
• HOWEVER, certain diagnoses are most likely
to occur in the acute care hospital setting.
– These include: Sepsis, Acute respiratory Failure,
Malnutrition, Aspiration pneumonia
General rules for other
(additional) diagnoses
• For reporting purposes, the definition for
“other diagnoses” is interpreted as
additional conditions that affect patient
care in terms of requiring:
– clinical evaluation; or
therapeutic treatment;
or diagnostic procedures;
or extended length of hospital stay;
or increased nursing care and/or monitoring.
The UHDDS item #11-b
• Other diagnoses as “all conditions that
coexist at the time of admission, that
develop subsequently, or that affect the
treatment received and/or the length of
stay. Diagnoses that relate to an earlier
episode which have no bearing on the
current hospital stay are to be excluded.”
Example from a recent audit
•
75-yr-old patient admitted with Sepsis (this is documented, and was
coded), in addition, the patient also has a history of hypertension as
well as glaucoma, which is documented and coded.
•
On admit to ICU, the patient was put on a Bipap, and ABGs were
abnormal x2 over 24 hrs. (No documentation of possible or confirmed
respiratory compromise in the chart by the provider). Patient was
treated with antibiotics and progress note lists “PNA,” but the patient
continues downhill after 5 days.
– What was the risk of mortality?
– Was this patient sicker than the data shows?
– Did we get the accurate reimbursement?
– Were all HCCs documented?
•
Action: Query or discuss with the physician
•
Result: Respiratory Failure = 518.81 (ICD-9-CM) = HCC 79
Example from a recent audit
• 86-year-old with CHF admitted with SOB, edema, and weakness. Hx
of diabetes type II. Put on O2, and Respiratory therapist noted the
patient was hypoxic but no documentation by the provider of this.
(Cannot code from the Respiratory Therapy note.) Per nursing
assessment, patient has diabetic peripheral neuropathy, and
blood sugar was 350 on sliding scale. Blood sugar drawn over 3
days, not documented by the provider (cannot code from nursing
notes but they do provide clues).
–
–
–
–
What was the risk of mortality?
Was this patient sicker than the data shows?
Did we get the accurate reimbursement?
Were all conditions addressed?
• Action: Query or Discuss with the physician
• Result:
– Hypoxemia = 799.02 (ICD-9-CM) = $5427 HCC 79
– Diabetic peripheral neuropathy = 250.70 (ICD-9-CM) = $4769 HCC 15
Risk score
• Male, 80 years old: demographic score – 0.597
HCC 18 – Diabetes with Ophtho – 0.259
HCC 80 – Congestive Heart Failure – 0.410
HCC 108 – COPD – 0.399
• Total Risk score = 1.665
• Divide by normalization factor of 1.03, risk score
= 1.616
Data submission is vital
• Data submission occurs rather than
individual UB-04 claims
• Data is submitted twice a year usually
• Retrospective resubmission of data is
allowed
• Retrospective documentation and coding
audits should be routine
– The time limit IS NOT the same as MS-DRGs
– 2008 data resubmission can occur up to the
end of 2009 and so on
Risk Adjustment vs.
Fee for Service (FFS)
• Key differences between Risk Adjustment and Fee for
Service:
– Ambulatory FFS payments are driven by visit/volume and
number and level of procedures (including CPT E/M) whereas
ambulatory risk adjustment payment is driven by ICD-9-CM
diagnoses.
– For risk adjustment, each diagnosis must be captured once per
calendar year in a face-to-face visit with a CMS recognized
provider (physician, NP, PA, etc.). Visit volume is not relevant.
– Inpatient FFS payments are driven by DRGs assigned which are
grouped for each discharge. Principal diagnosis and secondary
diagnosis are key. Risk adjustment, DRGs are not relevant but
the diagnosis and secondary Dx count on an annual basis.
– For risk adjustment, payment does not vary based on site of
service. Diagnosis sources are inpatient & outpatient hospital
and physician settings. FFS payment methodology varies by site
or setting.
National healthcare budget
perspective
NCAL Kaiser CDI program
Get the right information, in the right place, at the right time
EHR
CDI mission and vision
• To provide and sustain accurate, timely,
and complete clinical documentation in
support of
– Patient safety and quality of care
– Improved coding and data for internal and
external users and reporting
– Accurate and comprehensive reimbursement
CDI goals
• Understand the importance of documenting the patient’s
acuity of illness by capturing the severity of illness (SOI) and
risk of mortality (ROM) – the patient’s overall disease burden
• Accurately capture this information in the medical record
• Become familiar with ICD-9-CM codes that impact
reimbursement in the CMS-HCC model
• Understand IPPS MS-DRG payment methodology and the
impact of MCC/CCs
• Ensure that updated diagnoses (e.g., obtained through
diagnostic studies) are added to the medical record
• Ensure that information documented in the inpatient medical
record is translated into specific, codable diagnoses
Clinical Documentation
Integrity Program
• Initiatives
– Provide HCC training for CDI Consultants
– Perform concurrent chart reviews to ensure documentation
reflects the severity of illness of patients
– Work with the providers when documentation is incomplete
or vague
• Results
– Documentation will more accurately reflect the severity of
illness of the patient
– Reimbursement will be more appropriate for the care that
is rendered to each patient
What will the clinical
documentation program NOT do?
• It does not challenge the physician's medical
decision-making
• It does not make the physician into a coder
• It does not make the CDI consultant into a
physician or into a hospital coder
• It does not require more time to document
completely
• It does not alter – but rather enhances –
documentation
The CDI compliance connection
• Clinical documentation improvement and the
role of the Clinical Documentation Integrity
Consultants (CDIC) staff are an important
component of our regional compliance program.
– Senior Consultant and Consultant – partnership of
clinical and HIM professional
• By communicating, promoting, and partnering
with physicians for improved clinical
documentation, the hospital may reduce the risk
for submitting claims that are insufficient,
incorrect, or lack medical necessity.
Documentation
• Document – To document a chronic, co-existing condition is
to list it in the encounter note as a condition that exists and is
considered in the Medical Decision-Making process in
determining treatment.
• Address – To address the condition is to provide a written
statement of the condition and its status. It is not necessary to
treat the condition to address its status.
• Capture – To capture the diagnoses is to add the diagnoses
to the encounter or to choose a diagnosis from the
KPHealthConnect (EMR) that best describes and represents
the condition. It can also be added to the patient condition
problem list.
Implementation approach
• Phase I – Medicare Advantage Admissions
– HCC Focus – 20 specific diagnostic categories
• Phase II – All Medicare Admissions
– Medicare Advantage
– Medicare Cost and Fee-for-service
– HCCs, MS-DRGs, APR-DRGs
• Phase III – All Hospital Admissions
– This will depend on staffing requirements
PHASE I – HCC focus
• Medicare Advantage Reimbursement is
based on the Hierarchical Condition
Categories (HCC):
– We are reimbursed based on the most severe
diagnoses within each category (HCC)
– Disease categories are additive — that is,
reimbursements are based on the sum of all
chronic conditions diagnosed in different
categories
– Concurrent query and QA process
PHASE II – Case Mix Index
(DRG-based)
• The average of all DRG relative weights (RW) for all
discharged cases within a given time frame
• For Medicare
– Can be multiplied times the hospital blended rate to render
–
–
–
–
an expected Medicare reimbursement revenue. (RW x
blended rate = payment)
Reflects the severity of the patient population served; a
tertiary hospital should have an increased CMI in
comparison to a rural hospital
Is dependent upon the documentation within the medical
record
Is generally used as a benchmark measure for senior
leadership
This can indicate documentation or coding problems exist
PHASE III – all payers
(Case Mix Index impacted)
• Review of all payers – inpatient setting
• Target those that impact quality and
outcomes
• All inpatient cases are grouped to MSDRG
• Review OSHPD (Office State Hospital
Discharge) – California specific quality
indicators
PHASE I, II, and III –
principal and secondary diagnosis
Principal Diagnosis
• That condition
established after study,
determined to have
caused the patient’s
admission to the hospital
(UHDDS).
Documentation that is codable
Secondary Diagnosis
• Secondary diagnosis is
any condition that is
documented by the
physician and one of the
following:
(1) Clinically evaluated, or
(2) Diagnostically tested, or
(3) Therapeutically treated, or
(4) Causes an increased
Length of Stay (LOS) or
nursing care
Roles and responsibilities:
Clinical Documentation Integrity Sr Consultant (CDISC)
• Reviews the medical record on a concurrent basis to
identify and ensure all diagnoses are documented.
• Identify and communicate trends, lessons learned, and
issues.
• Engage Physicians to promote documentation best
practices.
– Partner with Physician Champion to ensure program success.
• Align program goals with coding requirements:
– Maintain current knowledge of coding guidelines (AHA Coding
Clinic).
– Maintain ongoing communication regarding Clinical
Documentation Integrity Program progress with coding team.
– Serve as liaison between physicians and HIM inpatient coding
professionals.
CDI program role clarity
•
Clinical Documentation Integrity Director – Regional
–
•
Clinical Documentation Integrity Managers (2) – Regional
–
•
Responsibilities per job description. Medical Center sponsor for CDIP. Interact and communicate
with CDI staff on a regular basis. Coordinate and Participate in CDIP meetings
Coding Supervisor – Medical Center HIM Department
–
•
Conduct QA review on CDI queries, check wording for compliance, provide guidance and feedback.
HIM Director – Medical Center HIM Department
–
•
Oversee CDI QA Staff and Review on Clinical Documentation Integrity Program (CDIP) work.
Gather and present Regional CDIP QA data to appropriate audience. Attend physician meetings
and present data/stats.
CDI QA Consultants – Regional
–
•
Conduct oversight and supervisor CDI consultant staff within Clinical Documentation Integrity
Program (CDIP). Gather and present Regional CDIP data to appropriate audience. Develop and
provided education as needed to CDIC staff. Attend physician meetings and present data/stats.
Clinical Documentation Integrity QA Manager (1) – Regional
–
•
Overall responsibility for the Clinical Documentation Integrity Program in the NCal Region.
Oversight of day to day operations of CDI program and staff. Lead regional CDI Steering
Committee.
Responsibilities per job description. Participate in CDIP Meetings.
HIM Inpatient Coding Staff – Medical Center HIM Department
–
Abstract and Code inpatient charts as per job description. Participate in
CDIP meetings as requested.
Roles and responsibilities:
Physician champion & treating physicians
Treating Physicians
• Document diagnoses to the
highest level of specificity.
• Maintain complete and
accurate medical record
documentation.
• Work with CDI Consultant to
respond to queries.
Physician Champion
• Provide leadership to the
facility and regional CDI
team.
• Facilitates the integration of
accurate, comprehensive,
and concurrent
documentation into daily
practices for physicians and
residents and other clinical
personnel.
• Facilitates standard uniform
documentation practices in
all settings.
Concurrent vs.
retrospective queries
• Concurrent Queries
– Pose questions “real time”
– Generally reduce the amount of HIM Coding rebill and
retrospective queries
– Focus is on “Dear Doctor” queries via EMR
• Pre-Bill Queries
– Generally posed by coding professional following discharge
(after the chart is closed, but before the claim is billed)
– Risk for delay in billing; and increase in discharged not final
billed accounts (DNFB) pending query response
• Retrospective Queries
– After the coding has been completed and the claim/acct has
been billed or paid
• Disadvantages of Retrospective Queries
– Physician recall compromised due to timing
– Generally time consuming to place query
and await follow-up
Concurrent query example
• Scenario
– The CDI Consultant examines a chart day 3 of the patient’s
hospital stay. The patient presented with a fever of 101,
productive cough, pleuritic pain, and was diagnosed with
pneumonia. He has a history of COPD on home 02. The patient
was being treated with Zithromax for a vague URI outpatient
prior to admission. The patient is now placed on two IV
antibiotics; both having gram negative coverage properties.
• Risk Factor – COPD with home 02 (tubing is a breeding ground for
bacteria)
• Sign/Symptoms-fever, productive cough, pleuritic pain, failed outpatient
treatment
• Treatment-Acute hospitalization, multiple IV antibiotics
• Query
– The CDI Consultant queries the physician, asks to clarify and
document whether she is empirically treating a suspected
specific type of pneumonia (listing choices provided)
Concurrent query example
• Scenario
– The CDI Consultants examines a chart day 3 of the
patient’s hospital stay. She notes that the patient was
admitted via the ED for an ORIF of his tibia/fibula
fracture. The progress note indicates the patient has
rales on the second day post-op and a slight fever
with oral antibiotics started.
• Query
– The CDI Consultant concurrently queried the
physician asking for the clinical diagnosis related to
the postoperative rales, fever, and antibiotics ordered.
When to query
• The following situations are examples of when it is
appropriate to query the physician for documentation
clarification:
– Clinical indicators of a diagnosis, but no documentation of the
–
–
–
–
–
diagnosis
Clinical evidence for a higher degree of specificity or severity
A cause-and-effect relationship between two conditions or
organisms
An “underlying cause” when admitted with symptoms
The treatment is documented, but not the associated diagnosis
Present on Admission (POA) indicator status for a documented
diagnosis
AHIMA. Practice Brief, “Managing an Effective Query Process" Journal of
AHIMA 79, no.10 (October 2008): 83-88
When to query (cont.)
• It is appropriate to query the healthcare provider
for clarification and additional documentation
regarding:
– Conflicting, incomplete, or ambiguous information in
the health record.
– Abnormal findings (laboratory, x-ray, pathologic, and
other diagnostic results), which cannot be coded and
reported unless the healthcare provider indicates their
clinical significance.
– Secondary conditions or diagnoses noted by nurses
and/or other ancillary personnel, which cannot be
coded and reported unless the healthcare provider
documents that they are clinically significant as a
current diagnosis.
When NOT to query
• Queries should not be used to question a provider’s
clinical judgment, but rather to clarify documentation
when it fails to meet criteria for completeness, clarity,
consistency, or precision.
• Queries may not be appropriate simply because the
clinical information or clinical picture does not appear
to support the provider’s documentation of a
condition or procedure.
– Example: documentation of acute respiratory failure in a
patient whose laboratory findings do not appear to support
this diagnosis.
VIA EMR … ‘Dear Doctor’
note process
HCC and diagnosis focus areas –
common for inpatient setting
HCC
Condition
Body System/Disease
Group
1
2
Sepsis (w/ pneumonia), SIRS, shock, UTI
Infectious Disease
2
7
Metastatic Cancer (all)
Neoplasm
3
10
Cancer: Prostate, Breast, Colorectal, and other
cancers and tumors
Neoplasm
4
15
Diabetes w/ CKD or PVD
Endocrine/Nutrition & Metabolic
5
16
Diabetes w/ Neuropathy and other
manifestations
Endocrine/Nutrition & Metabolic
6
21
Protein Calorie Malnutrition (type/degree)
Nutrition & Metabolic
7
79
Respiratory Failure (all)
Respiratory System
8
105
PVD (with and without Complication)
Vascular System
9
131
Renal Failure/disease (include dialysis status)
Renal/Urinary system
HCC and diagnosis
focus areas (cont.)
HCC**
10
111, 112
11
80, 81, 82, 83,
92
12
148, 149
Condition
Body System/Disease
Group
Pneumonia *
Respiratory System
Cardiac (heart failure*/shock, cardiac
Cardiac/Circulatory System
arrhythmia, acute MI,* old MI, angina)
Pressure ulcers (Cellulitis and all other
Disease of the Skin
chronic ulcers)
13
75, 95, 96
Stroke*/CVA/Hemorrhage (coma)
Nervous System
14
100
Stroke*/CVA residual deficit
Nervous System
15
154, 155
Head Injuries (Trauma)
Trauma/Injury
16
157
Vertebral Fractures (Trauma)
Trauma/Injury
17
158
Hip Fractures (Trauma)
Musculoskeletal System
18
161
Traumatic Amputation (include status)
Injury
19
176
Artificial Opening feeding/Ostomies
2nd Dx
(status)
20
177
* Core Measures
Amputation Status and Complications
2nd Dx
Using the problem list – capturing systemic
diagnosis – correlates with AHA Coding Clinic
• Per KP policy (from National Compliance) a systemic
condition is defined as one which:
– It is always present, even though it may have been
stabilized; AND
– By its very nature (because of its impact on the patient),
requires that it be considered by the physician in
evaluating the patient’s chief complaint; AND
– The condition affects a major body system (and typically,
more than one major body system) which include the
following:
•
•
•
•
•
•
Cardiovascular; and/or
Respiratory; and/or
Renal; and/or
Hematolgocia/Lymphatic/Immunologic; and/or
Neurologic; and/or
Psychiatric
CDI tools
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Clinical Documentation Integrity Review Sheet
Clinical Documentation Integrity Tracking Log
Hospital Census Report
Shared Patient List Report
Medical Diagnosis Prompt Report
Hospital Discharge Report
CDI QA Review Sheet
CDI QA Tracking Log
CMS MA HCC & ICD-9-CM List
3M Encoder Software
DRG Expert (Ingenix)
AHIMA Practice Brief “Managing the Physician Query
Process”
Tracking log
CDI QA audit and processes
• The quality assurance audits will monitor, measure and/or
evaluate the following:
– The accuracy of HCC assignment and presence or absence of
–
–
–
–
–
–
–
documentation
The appropriateness and rationale for issuing a query
The adequacy of documentation to support the MS-DRG
assignment
The identification of secondary diagnoses that support Severity
of Illness (SOI)
The validation of the HCC after the chart has been coded
The identification of potential compliance issues such as leading
queries
The timeliness, response rate, and agreement rate of the
physician staff
The identification of additional CDISC staff individual or group
training needs
CDI QA
• The quality assurance standards for CDISC staff are as
follows:
– Week 1 onsite at Medical Center: 100% of charts reviewed by the CDISC
staff will be audited by the Clinical Documentation Integrity Consultant
(CDIC) QA staff. Results will be documented and summarized in the CDI
QA tool. CDISC staff must perform at 95% or higher as reported in the CDI
QA summary report.
• If the 95% target is achieved as a result of the Week 1 audit, 50% of the charts reviewed by
•
•
the CDISC staff will be audited by the CDIC QA staff during Week 2.
If the 95% target is maintained as demonstrated by the Week 2 audit results, for Week 3 and
Week 4, 25% of the charts reviewed by the CDISC staff will be audited by the CDIC QA staff.
If the 95% target is maintained for Weeks 1 through 4, audits will be on a regular schedule:
5% of charts reviewed or 25 charts per CDISC.
– If the 95% target is not reached as shown by the Week 1 audit results,
100% of the charts reviewed by the CDISC staff will be audited by the CDIC
QA staff during Weeks 2, 3, and 4 or until the 95% target is achieved.
– During the initial four weeks, targeted education will be provided to CDISC
staff to help address any deficiencies found during the quality assurance
audits.
Expected CDI outcomes
Improved &
Increased
Compliance
Accurate
Capture of
Severity/Acuity
Improved Quality
Scores and Report
Cards
Improved Patient
Outcomes/Care
Strong
Documentation
Program
More Accurate
HCC and DRG
Assignment
More Appropriate
Reimbursement
Accurate
Capture of
Risk of
Mortality
Greater
Documentation
Specificity in Chart
CDI stats
(week ending 2/19/2010)
Week
Total Number
of Charts
Audited
Number of
HCCs
Validated
Valid HCCs
Found
Dec-2009
Jan-10
Week 10 (1/30 - 2/5)
Week 11 (2/6 - 2/12)
Week 12 (2/13 - 2/19)
Month-To-Date Totals
Year-To-Date Totals
0
119
44
70
23
137
256
0
54
23
9
11
43
97
0
35
10
7
6
23
58
% of Charts
Audited vs.
Admissions
38.55%
% HCC
% Valid
Validated vs.
HCCs Found
Total Number
vs HCCs
of Charts
Validated
Audited
37.89%
59.79%
CDI stats
Inpatient HCCs
(week ending 2/19/2010)
2/19/2010
Description
HCC 2 Septicemia/Shock
HCC 7 Metastatic Cancer and Acute Leukemia
HCC 10 Breast, Prostate, Colorectal and Other Cancers and
Tumors
HCC 15 Diabetes with Renal or Peripheral Circulatory
Manifestation
HCC 16 Diabetes with Neurologic or Other Specified
Manifestation
HCC 21 Protein-Calorie Malnutrition
HCC 79 Cardio-Respiratory Failure and Shock
HCC 105 Vascular Disease
HCC 131 Renal Failure
Queried
Actual
Validated
Estimated
Qty
Qty
Qty
Reimbursement Found $ Value
Agreed
Valid $ Value
$ Value
$7,235
9
$65,115
3 $21,705
3
$21,705
$21,695
0
$0
0
$0
0
$0
$1,983
0
$0
$4,842
29
$3,889
$8,159
$5,509
$3,012
$3,508
3
36
14
0
7
0
$0
0
$0
$140,418
21 $101,682
12
$58,104
$11,667
$293,724
$77,126
$0
$24,556
2
$7,778
29 $236,611
11 $60,599
0
$0
5 $17,540
2
22
11
0
4
$7,778
$179,498
$60,599
$0
$14,032
Top 10 HCCs
(week ending 2/19/2010)
Frequency of HCCs
4
4 31
6
36
7
9
14
29
HCC 21 Protein-Calorie Malnutrition
HCC 15 Diabetes with Renal or Peripheral Circulatory Manifestation
HCC 79 Cardio-Respiratory Failure and Shock
HCC 2 Septicemia/Shock
HCC 131 Renal Failure
HCC 148 Decubitus Ulcer of Skin
HCC 111 Aspiration and Specified Bacterial Pneumonias
HCC 80 Congestive Heart Failure
HCC 16 Diabetes with Neurologic or Other Specified Manifestation
HCC 157 Vertebral Fractures without Spinal Cord Injury
1422 charts reviewed; 115 queries submitted
Documentation tip
• Documenting “DM,” “NIDDM,” or “Diabetes controlled
with meds” can create poor data, indicate a lower level of
severity, and inaccurate payment
• Clearly define the type of diabetes the patient has
• Use the phraseology from the most appropriate ICD-9
codes, i.e., “type 1″ or “type 2″ diabetes and especially if
the diabetes mellitus is controlled or not controlled
• Document the manifestation of the diabetes also i.e.,
neuropathy
Ask about Medicare Advantage
• What % of your patients’ population are
MA?
• Conduct documentation and coding audits
on MA
• Data mining inpatient MA discharges
• Increase awareness and education
AHIMA CDI Practice Brief
• Clinical Documentation Improvement Program... A Model Guidance
• The following guidance does not replace the 2008 AHIMA Practice
Brief, Managing an Effective Query Process, It is, however, intended
to provide greater specificity and detail related to Clinical
Documentation Improvement programs.
• Healthcare consumers are unique. Each person has their own
combination of medical conditions that must somehow be
standardized for comparison. One way to capture this data is the
translation of clinical documentation into codes (e.g., ICD-9-CM or
CPT) which has traditionally been the domain of the Health
Information Management (HIM) professional. The domain of the
clinical professional has been the analysis of specific data quality
elements and how that data impacts patient care and outcomes.
Clinical Documentation Improvement
Program.... A Model Guidance
• Policies and Procedures
• CDI Role, Competencies and Staffing Models
• Role of the CDI Physician Advisor
• Query (Clarification)
• Leading/non-leading queries
• Conclusion
• CDI programs provide new opportunities for professionals in a
changing healthcare environment. CDI professionals have the
opportunity to lead their organizations in the documentation
improvement process and be a champion for quality, timely
documentation.
Clinical Documentation Improvement
Program.... A Model Guidance
• This practice brief will provide an overview of key
elements in establishing, maintaining and/or
enhancing a CDI program. This can be achieved
through a variety of methods and structure that are
tailored to the unique needs of the healthcare
entity.
• This brief includes the following sections:
– policies and procedures;
• the role, competencies, and staffing models for the CDI
professional;
• physician leadership; and
• query examples specific to CDI.
Summary
• Medicare Advantage is driven by
documentation and coding
• Understanding MA can help with hospital
• CDI should be inclusive of all Medicare
payers
• Track the payer types within your CDI
program
Resources/References
• Medical Care, Vol 43, Number 1, January 2005, pg. 34.
• Medicare HCC Coding is Mission Critical for HMOs, Sep
1, 2007, Al Lewis
• Risk Adjustment of Medicare Capitation Payments Using
the CMS-HCC Model, Healthcare Financing Review,
September 2004
• www.cms.hhs.gov/MMCAG/04_PartCRecon.asp
• HCC Blog, Risk Adjustment and Medicare Advantage by
– J. Matt Yuill, MD, CPC
• Kaiser Family Foundation
Thank you
Questions?