Post ICD-10 Clinical Documentation Improvement (CDI) Program Revitalization North Carolina Health Information Management Association

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1 Post ICD-10 Clinical Documentation Improvement (CDI) Program Revitalization North Carolina Health Information Management Association May 4, 2016 MeShawn Foster, RHIT, MJ Senior Consultant, Deloitte & Touche LLP Peggy Meli, PhD, RHIA, CHC, LHRM (FL) Specialist Master, Deloitte & Touche LLP 1

2 Session objectives Assess previous state (ICD-9) of CDI program against current state post ICD-10 Identify and leverage leading practices in clinical documentation and when to modify program with ICD-10 Discuss impact ICD-10 has had on CDI programs Discuss impact of technology systems with CDI programs Discuss key performance metrics to monitor CDI program s operations and success Better understanding of reimbursement systems 2

3 Introduction Revitalization of a CDI program is a proactive step that an organization may take to trend towards leading practices and enhance the quality of an existing program. Beginning with a state-to-state assessment can allow for identification of gaps, changes, and improvements. Previous state What were our processes? How was performance tracked and monitored? What technology was used? What was our program visibility? Current state 3 Have our processes changed? Did we modify our tracking and monitoring? What are our technology needs? How visible is our program?

4 State-to-state assessment A robust assessment should consider people, processes, tools and sustainability. WHO? PEOPLE TOOLS SUSTAINABILITY WHAT? HOW? PROCESSES 4

5 State-to-state assessment (cont.) What is the vision? Identifying Gaps Develop a vision for the CDI program that aligns with established leading practice goals Identify your stakeholders and obtain their buy in for continual improvement Develop an internal benchmark based on previous state peak results Define benchmarks for your organization Evaluate previous and current state against defined leading practices Document gaps and develop a strategy for minimization Continual Monitoring Perform initial monitoring as a comparative before transitioning to continual qualitative analysis Shift monitoring to accommodate productivity changes due to ICD 10 Develop ongoing monitoring process with automation where possible 5

6 CDI Program Sustainability Post ICD-10 Clinical Documentation Governance Physician and executive leadership engagement Physician communication Alignment with related enterprise initiatives (e.g., system replacement) Metrics & Performance Management Monitoring and reporting tools to track results in terms of case mix index (CMI), severity of illness (SOI), risk of mortality (ROM) and patient safety indicators (PSI) Clinical Documentation Stakeholder Collaboration Strong and consistent operational leaders and managers Teaming and communication between CDI Specialists, Coders and Physicians Enterprise Technologies & Tools Operational tools to drive daily workflow, documentation and tracking of work and exceptions flagging Clinical documentation customized query templates within the EMR and/or CDI tool Education and training tools in multiple formats Interoperable CDI tools Process Standardization Structured policies and procedures to standardize program requirements Specialty specific approach to physician training Consistent coding accuracy program Operational Sustainability Resilient governance structure Periodic external review and feedback Annual CDI Specialist and Coder training CDI performance metrics for physicians, CDI, coding and management 6

7 Identifying Leading Practices An organization may define leading practices according to best practices established by American Health Information Management Association (AHIMA) and Association for Clinical Documentation Improvement Specialists (ACDIS) Deloitte Advisory has developed a maturity model to help organizations determine the current state of the program compared to their desired future state. I Beginning II Developing III Effective IV Advanced V Exceptional The Maturity Model offers a structured mechanism to assess an organization s performance against industry leading practices. 7

8 Modifying Existing Programs Assessment results should provide an indication of how mature your current CDI program is along with identifying opportunities with ICD-10 to advance your program further. I - Beginning II - Developing III - Effective IV - Advanced V - Exceptional Processes Little to no policies and procedures Decentralized operations Polices and procedures exist but not documented Limited Centralization Standardized, documented, applied and enforced polices and procedures Polices and procedures are routinely tested to confirm compliance Serve as a model for other organizations; shared service centers 8

9 Common ICD-10 Impacts to CDI Programs ICD-10 has created opportunities to better capture medical necessity, further identify severity of illness, and enhanced detail of conditions and procedures that will lead to better management of healthcare quality. Documentation Understanding key focus areas for diagnoses that require specific documentation in order to be coded Emphases on translation of clinical language to coding language to better capture full clinical picture of patients Clarifying that Documentation of suspected, possible and probable conditions when treatment and monitoring is occurring is appropriate Reimbursement Recognizing overall DRG shifts due to changes between the code sets Performing mortality reviews for cases that have APR- DRG SOI and ROM that is less than 4 Identify top Medicare Severity Diagnosis Related Groups (MS-DRGs) and top surgeries and determine potential shifts and/or documentation challenges 9

10 Technology Selection of vended software is an essential element to advancing and revitalizing a CDI program post ICD-10. Is there interoperability with my EMR? What are the reporting capabilities? Will benchmarking be available? Is the return on investment substantial? 10

11 Key Performance Metrics Ongoing monitoring of key performance metrics enables tracking and trending towards a leading CDI program. Initial Review Volume Follow-up Review Volume CDI Metrics Query Rates (Concurrent and Retrospective) and DRG mismatch rates Physician Agreement and Response Rates 11

12 Sample KPI Metrics for CDI Sustainability and Continuous Improvement MCC/CC Capture tracking evaluates the frequency that a MCC/CC is captured on a bill Alternate Principal Diagnosis Opportunities considers instances where an alternate principal diagnosis may be selected based on documentation in the chart and/or a generated query Sign and Symptoms MS-DRG Frequency Analysis shows the trend of DRGs assigned to a sign and symptom/non-specific DRG CMI Improvement by Service Line demonstrates the trending of CMI changes by Medical and Surgical Specialties post CDI education and revitalization. Risk of Mortality and Severity of Illness Metrics displays trends of physician s risk of mortality, severity of illness and GMLOS for informational and physician educational purposes Coverage Analysis provides the percentage of Medical, Surgical, and Overall cases concurrently reviewed compared to the total Medicare population Query Rate and Physician Response Rate provides a comparative analysis of the number of queries generated against the number of physician responses. Physician Agreement Rate should also be monitored against the number of Both retrospective and concurrent queries are recommended to be tracked Actual Mortality Rates compared to Expected Mortality Rates by DRGs may be a useful metric to explore CDI/Coder Mismatch will compare the frequency of mismatches against reconciliation when the CDI s working DRG differs from the coder s final DRG 12

13 Understanding Reimbursement Systems Classification of inpatient stay resource intensity and illness severity is tied to reimbursement groupings. These groupings helps measure the case mix of an entity s patient population. MS-DRG MS-DRGs are assigned to each inpatient stay. MS-DRGs are divided into 25 major diagnostic categories (MDCs) Select diagnosis codes are categorized as major complications/comorbidities (MCCs) or complications/comorbidities (CCs) MS-DRGs have a weighted value depending on whether they are a single, pair or triplet combination inclusive of MCCs/CCs APR-DRG All Patient Refined Diagnosis Related Groups (APR-DRGs) focus on resource intensity There are 315 base APR-DRGs There are two sets of subclasses, SOI and ROM that are added to the base APR-DRG is driven by principal diagnosis, procedures performed, all secondary diagnoses, age and gender 13

14 Calculating Case Mix Index Case Mix Index is calculated using the average diagnosis related group relative weight for a hospital. DRG RW # of Cases Total RW 195 Simple pneumonia w/o MCC/CC Simple pneumonia with MCC Heart failure with MCC Heart failure w/o MCC/CC UTI w MCC Renal Failure with MCC Renal Failure w CC Septicemia w/o vent w MCC Septicemia w/o vent w/o MCC Intracranial hemorrhage or cerebral infarction w CC Total CMI = Sum of RW / Total # of Cases

15 Severity of Illness and Risk of Mortality The focus of the CDI department is to emphasis on improving the overall quality of the documentation regardless of the impact on CC/MCC capture SOI and ROM are scored on a scale of = minor 2 = moderate 3 = major 4 = extreme Recognizing the importance of SOI/ROM The mortality index is the ratio of actual deaths to expected deaths: Secondary diagnoses capture impacts to the expected mortality rate The SOI/ROM scores are a key component in the algorithm used to calculate the expected mortality rate How is the SOI/ROM determined? Each diagnosis has its own intrinsic SOI/ROM value of 1 4 A complex formula is used to calculate the SOI/ROM of the DRG/case In order for the DRG/case to be a 4/4, at least two diagnoses used to calculate the DRG must have a value of 4/4 15 Through complete documentation, physicians accurately represent their patient s severity of illness and risk of mortality

16 Reimbursement Systems and Your Patient Without Accurate and Complete Documentation With Accurate and Complete Documentation Primary Diagnosis Urosepsis Septicemia Secondary Diagnoses Dehydration Dehydration COPD COPD Medicare DRG 690: Kidney and Urinary Tract Infection UTI Malnutrition Stage 1 Pressure Ulcer Septic Shock 871: Septicemia w/o MV Medicare Relative DRG Weight Reimbursement: $4600 $10, ~$ change MS-DRG Expected Length of Stay 3.1 days 5.1 days 2 days added APR DRG Severity of Illness Level 2 Moderate 4 Extreme Risk of Mortality Level 2 Moderate 4 Extreme SOI Weight X increase 16 Expected Mortality Rate 1.0% 47.4% 46 point increase

17 Key Takeaways ICD-10 offers an opportunity to obtain better quality data due to the specificity offered within the code set A leading CDI program can leverage ICD-10 with a focus on documentation that should better reflect the severity of the patient substantiating resource use A leading CDI program should have a holistic approach that considers quality, complete documentation and reimbursement A leading CDI program increases MCC and CC capture, reflects the correct SOI/ROM values and potentially raises case mix Known shifts should be examined and monitored to determine their impact post ICD-10 17

18 Questions Q A 18

19 Appendix Bios and Contact Information 19

20 Speaker Bios Vickie Monteith, RN, MBA, Deloitte Advisory Director, Deloitte & Touche LLP Vickie is Deloitte Advisory s national leader for the ICD-10 and Clinical Information Integrity and Maturity (CIIM) solutions, and co-leads the Clinical Documentation Excellence (CDE) practice. She has Qmore than 27 years of experience in the healthcare industry in the areas of scheduling, patient access, medical necessity processing, utilization management, case management, medical records, patient accounting, A billing compliance, charge integrity, chartto-bill audits, CDE, charge description master (CDM) reviews and standardization, compliance risk assessments, compliance effectiveness reviews, compliance program development, internal control reviews, Recovery Audit Contractor (RAC) readiness, Medicare compliance, ICD-10, nursing, and supply chain. Peggy Meli, PhD, RHIA, CHC, LHRM, Deloitte Advisory Specialist Master Deloitte & Touche LLP Dr. Peggy Meli provides HIM operations, coding and clinical documentation reviews as well as Legal EHR designation, release of information operations, HIPAA compliance, ICD-10- CM/PCS coding, HIM IT coordination and healthcare risk management functions, training and educational solutions for healthcare facilities and physician practices. Peggy s recent engagements at Deloitte Advisory include HIM Interim Management, ICD-10 implementation and charge capture review, Clinical Documentation Excellence and monitoring, ICD-10-CM/PCS Training and Implementation and HIM and coding review and process improvement. Additional engagements have included professional fee (E& M) coding, auditing, and physician compliance reviews. 20

21 Speaker Bios, cont. MeShawn Foster, MJ, RHIT, Deloitte Advisory Senior Consultant Deloitte & Touche LLP MeShawn is a senior consultant in Deloitte s Advisory health care practice with significant health information management experience focusing on finance, operations, and risk transformation Qin both the provider and payer environments. MeShawn possesses robust and diverse experience in end-to-end revenue cycle, data management governance, information governance, health system implementation, A remediation, provider auditing, clinical documentation improvement, data analysis, ICD-9, ICD-10 and CPT coding and billing, payer system remediation, policy development, legal research, and technical solutions. 21

22 Contact Information Vickie Monteith Director Deloitte Advisory Deloitte & Touche LLP Q MeShawn Foster Senior Consultant Deloitte Advisory Deloitte & Touche LLP Peggy Meli Specialist Master Deloitte Advisory Deloitte & Touche LLP

23 Disclaimer This presentation contains general information only and Deloitte Advisory is not, by means of this presentation, Q rendering accounting, business, financial, investment, legal, tax, or other professional advice or services. This presentation is not a substitute for such professional advice or services, nor should it be used as a basis for any decision or action that may affect your business. Before making any decision or taking any action that may affect your business, you should consult a qualified professional advisor. Deloitte Advisory shall not be responsible for any loss sustained by any person who relies on this presentation. As used in this document, Deloitte Advisory means Deloitte & Touche LLP, which provides audit and enterprise risk services; Deloitte Financial Advisory Services LLP, which provides forensic, dispute, and other consulting services; and its affiliate, Deloitte Transactions and Business Analytics LLP, which provides a wide range of advisory and analytics services. Deloitte Transactions and Business Analytics LLP is not a certified public accounting firm. These entities are separate subsidiaries of Deloitte LLP. Please see for a detailed description of the legal structure of Deloitte LLP and its subsidiaries. Certain services may not be available to attest clients under the rules and regulations of public accounting. 23