Thinking Outside the Inpatient Box: Preparing for the Future with Clinical Documentation Improvement in the Ambulatory Care Setting
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1 Thinking Outside the Inpatient Box: Preparing for the Future with Clinical Documentation Improvement in the Ambulatory Care Setting 2015 Nuance Communications, Inc. All rights reserved.
2 Presenters Today Kimberly Hopey, PhD, RN Director, Professional Services, Nuance Communications-Healthcare Division/ J. A. Thomas & Associates Angela Carmichael, MBA, RHIA, CDIP, CCS, CCS-P Director, Health Information Management, Nuance Communications-Healthcare Division/J. A. Thomas & Associates 2014 Nuance Communications, Inc. All rights reserved. 2
3 Agenda What are the Drivers of Ambulatory CDI? Inpatient vs. Ambulatory CDI Similarities and Differences Developing an Ambulatory CDI Strategy Risks and Opportunities Best Practices and Critical Success Factors Ambulatory CDI Models Model Considerations and Options Value to Patient and Provider Summary 2014 Nuance Communications, Inc. All rights reserved. 3
4 Why is Advancing CDI Beyond the Inpatient Walls a Strategic Imperative? Healthcare reform driven by the Affordable Care Act (ACA) is geared to improve quality, affordability and access to care through the key focus areas below. Transition to value-based payment Improve care delivery through innovation Expand information sharing including increased transparency on cost and quality for better consumer decision making Increased regulatory oversight and scrutiny Shift to outpatient services 2014 Nuance Communications, Inc. All rights reserved. 4
5 Accelerated Transition To Value-Based Payment Source: CMS Fact sheets: Better Care. Smarter Spending. Healthier People: Paying Providers for Value, Not Volume. 01/26/ Nuance Communications, Inc. All rights reserved. 5
6 Impact on Providers Source: CMS Fact sheets: Better Care. Smarter Spending. Healthier People: Paying Providers for Value, Not Volume. 01/26/ Nuance Communications, Inc. All rights reserved. 6
7 Center for Medicare & Medicaid Innovation 2014 Nuance Communications, Inc. All rights reserved. 7
8 Physician Payment: Value Modifier and PQRS Source: 2015 Medicare Physician Fee Schedule (MPFS) Final Rule, CMS/MLN National Provider Call, 12/02/ Nuance Communications, Inc. All rights reserved. 8
9 Timeline for Phasing in the VM Source: How to Register for the PQRS Group Practice Reporting Option in 2015, CMS/MLN National Provider Call, 04/16/ Nuance Communications, Inc. All rights reserved. 9
10 Medicare Access and CHIP Reauthorization Act (MACRA) of 2015: New Mandates 2014 Nuance Communications, Inc. All rights reserved. 10 Source: CMS Quality Reporting Programs under the 2016 Medicare Physician Fee Schedule Proposed Rule, CMS/MLN National Provider Call, July 16, 2015
11 Merit-Based Incentive Payment System (MIPS) Source: CMS Quality Reporting Programs under the 2016 Medicare Physician Fee Schedule Proposed Rule, CMS/MLN National Provider Call, July 16, Nuance Communications, Inc. All rights reserved. 11
12 MACRA: Promotes Alternative Payment Models (APMs) 2014 Nuance Communications, Inc. All rights reserved. 12 Source: CMS Quality Reporting Programs under the 2016 Medicare Physician Fee Schedule Proposed Rule, CMS/MLN National Provider Call, July 16, 2015
13 So Who s Watching? 2014 Nuance Communications, Inc. All rights reserved. 13
14 Medicare FFS 2014 Improper Payments Report Top 15 Part B Service Types with Highest Improper Payments Nuance Communications, Inc. All rights reserved. 14
15 Medicare FFS 2014 Improper Payments Report Top 15 Part B Service Types with Highest Improper Payments: Evaluation & Management Services Subset Part B Services (BETOS Codes) Hospital visit - subsequent Projected Improper Payments Improper Payment Rate 95% Confidence Interval No Doc Insufficient Doc Type of Error Medical Necessity Incorrect Coding Other $1,174,125, % 18.9% % 4.40% 53.90% 0.10% 41.30% 0.30% Office visits - established $1,042,121, % 6.2% - 8.2% 3.00% 30.30% 0.00% 66.70% 0.00% Hospital visit - initial $912,148, % 29.1% % 1.60% 31.50% 0.00% 66.60% 0.40% Office visits - new $459,363, % 14.4% % 0.00% 15.90% 0.00% 79.70% 4.50% Emergency room visit $311,925, % 11.7% % 0.00% 29.10% 0.00% 69.30% 1.60% Hospital visit - critical care $294,609, % 23.6% % 0.00% 46.90% 0.00% 47.00% 6.10% Items/Downloads/AppendicesMedicareFee-for-Service2014ImproperPaymentsReport.pdf?agree=yes&next=Accept 2014 Nuance Communications, Inc. All rights reserved. 15
16 Medicare FFS 2014 Improper Payments Report Top 15 Types of Services with Insufficient Documentation Errors All Services Improper Payment Rate Projected Improper Payments 95% Confidence Interval Home Health 46.30% $8,457,512, % % Hospital Outpatient 7.30% $3,305,285, % % SNF Inpatient 5.20% $1,844,226, % - 6.8% Clinic ESRD 10.40% $1,138,589, % % Lab tests - other (non-medicare fee schedule) 33.80% $1,001,069, % % Oxygen Supplies/Equipment 58.50% $897,402, % % Minor procedures - other (Medicare fee schedule) Insufficient Documentation Errors 23.80% $761,170, % % Hospital Inpatient (Part A) 6.60% $638,414, % - 8.9% Hospital visit - subsequent 11.20% $633,004, % % Ambulance 10.10% $582,984, % % Glucose Monitor 48.30% $573,785, % % CPAP 44.50% $344,090, % % Office visits - established 2.20% $315,389, % - 2.9% Specialist - psychiatry 27.90% $307,493, % % Hospital visit - initial 9.80% $286,878, % % Nuance Communications, Inc. All rights reserved. 16
17 Shift To Outpatient Services Source: Medicare Payment Advisory Commission s March 2015 Report to the Congress: Medicare Payment Policy. March 13, Nuance Communications, Inc. All rights reserved. 17
18 Shift To Outpatient Services Source: Medicare Payment Advisory Commission s March 2015 Report to the Congress: Medicare Payment Policy. March 13, Nuance Communications, Inc. All rights reserved. 18
19 CDI in the Ambulatory Setting 2015 Nuance Communications, Inc. All rights reserved. 19
20 Ambulatory CDI (AKA Outpatient CDI) Goals and Objectives: To ensure complete, accurate, and compliant clinical documentation, coding and billing resulting in an accurate reflection of patient severity, the level of services provided, quality of care delivered, and reimbursement Nuance Communications, Inc. All rights reserved. 20
21 Inpatient CDI Ambulatory CDI Key differences in the ambulatory setting: Volumes are significantly higher. Timeframes for episodes of care are significantly shorter. Multiple and different code sets, guidelines, claim forms, and payment methodologies depending on ambulatory setting. Role of non-physician documentation Nuance Communications, Inc. All rights reserved. 21
22 Inpatient CDI Ambulatory CDI Key differences in the ambulatory setting (cont.): Setting specific workflows, roles, and operational differences. Deeper involvement and more complexity in the revenue cycle. Clinical documentation Coding Billing Payment 2014 Nuance Communications, Inc. All rights reserved. 22
23 Ambulatory CDI Strategy: Where to Begin? Three broad areas of opportunity: OPPS/ASC Hospital-based outpatient departments, clinics, or centers Community-based ambulatory care, surgery and diagnostic procedure centers Physician Fee Schedule Hospital/Health System (HS) Employed Physician Group Practices Private Independent Physician Group Practices Risk Adjustment (RA) Payment Methodologies Hospital/HS that: Own a Medicare Advantage (MA) health plan Employ physicians with MA contracts that include RA score incentives Participate in an ACO Nuance Communications, Inc. All rights reserved. 23
24 Ambulatory CDI Strategy: Where to Begin? Key general discovery questions about these three areas: How is clinical documentation captured? What is the coding process? What is the billing process? Who oversees the revenue cycle? Are the physicians employed or private practice? What are the driving concerns for the areas: Claim denials Adverse external audits/compliance concern Revenue generation/underperformance AR Days New service line Regulatory changes Additional questions applicable to RA MA health plan ownership or ACO participation? Employed physician incentives? 2014 Nuance Communications, Inc. All rights reserved. 24
25 Ambulatory CDI Strategy: Where to Begin? Analyze your claims denials for patterns and trends to narrow down your focus. If under Risk Adjustment, what does your aggregate Risk Adjustment Factor score tell you? Prioritize the area that will bring most value to the organization and then stay focused Nuance Communications, Inc. All rights reserved. 25
26 Best Practices and Critical Success Factors Auditing Best practice includes regular, periodic external audit by credentialed specialty coder/auditor Include high risk compliance target areas in addition to areas exposed by denial analysis Assess clinical documentation, coding, billing, and remittance advice for end-to-end evaluation Uncovers risks as well as missed opportunities due to undercoding/underbilling Answers the why? Is deficiency due to insufficient clinical documentation, coding error, or billing error Identifies systems issues, educational needs, etc Nuance Communications, Inc. All rights reserved. 26
27 Best Practices and Critical Success Factors Education/Training Based on audit findings/assessed needs Routine education on general and specialty specific Fed/State regulations and guidelines, as well as private payer policies Organizational policies/procedures including compliance program and ethics Peer-to-peer and/or interdisciplinary education targeted to audience 2014 Nuance Communications, Inc. All rights reserved. 27
28 Best Practices and Critical Success Factors Engagement and collaboration Leadership: Executive, physician, department/practice, CDI, HIM, revenue cycle, quality, IT Physicians/Non-physician providers Staff: Department/Practice, coding, billing, CDI specialist Leverage technology & tools: Current and future Ensure EHR and/or paper templates, forms and flow sheets meet current documentation guidelines; routinely review Speech recognition technology to improve capture of individualized narrative documentation at the point of care Smart text/documentation prompts and tip sheets CAC CAPD 2014 Nuance Communications, Inc. All rights reserved. 28
29 Best Practices and Critical Success Factors Assess and redesign workflows specific to the setting to maximize complete, accurate, efficient and compliant processes with seamless handoffs and minimal rework Pre-visit data collection and preparation Physician vs. coder assignment of codes from documentation Chart completion Ongoing data analytics, auditing and monitoring to sustain improvement and proactively identify new issues due to changes in guidelines, rules and regulations Formalize your denial management process 2014 Nuance Communications, Inc. All rights reserved. 29
30 Ambulatory CDI Model Considerations CDI is an ongoing interdisciplinary process it is not a single person or role While there may be a specialized role in place or one instituted, it still requires a team approach to be effective Approach must be customized to the setting Size/Number of locations Patient volume and pace of work area Length of encounter time Workflow Financial and talent bandwidth Available technology 2014 Nuance Communications, Inc. All rights reserved. 30
31 Ambulatory CDI Model Options Pre-visit Model: Clinical records from prior visits reviewed prior to patient encounter and physician clarifications sought by CDI specialist before patient is seen Sites to consider: Physician Office with RA payment/incentive, high dollar imaging or surgery/procedures areas Advantages: Proactive real time capture of previously under documented chronic conditions, ensure pre-procedure medical necessity documentation per NCD/LCD is documented Concurrent or Pre-Bill Model: Clinical records reviewed during or immediately following patient encounter Sites to consider: Those with longer encounter times such as Emergency Department, Observation Unit, Infusion Centers Advantage: Identify issues and resolve during or shortly after encounter but prior to billing to prevent denials/re-work 2014 Nuance Communications, Inc. All rights reserved. 31
32 Ambulatory CDI Model Options Retrospective Model: Post bill audit/review with strong focus education, tracking and trending Sites to consider: High volume/short encounter times such as physician offices, labs, or routine radiology; smaller sites with limited resources Advantage: Focused strategy for education, prevention, and mitigation Nuance Communications, Inc. All rights reserved. 32
33 CDI Specialist Role To date, there been little penetration of the CDI Specialist role into the ambulatory setting. According to a 2014 AHIMA Foundation Clinical Documentation Improvement Job Description Summative Report, which reviewed 337 randomly selected CDI Specialist job descriptions, 99% of the job locations were in the acute care setting. Source: Clinical Documentation Improvement Job Description Summative Report ahimafoundation.org 2014 Nuance Communications, Inc. All rights reserved. 33
34 CDI Specialist Role There is no ONE single discipline that will meet the unique needs and challenges across the multiple types of ambulatory settings. You must match the skill set to the needs of the setting. Creating a cross functional and interdisciplinary team with complimentary skill sets is ideal. For example: Nursing is well suited in RA settings where reviewing complex patient records to uncover missed diagnoses Certified specialty coders are especially well suited in specialty procedure areas due to their CPT coding knowledge 2014 Nuance Communications, Inc. All rights reserved. 34
35 Clinical Documentation Improvement is no longer relegated to the Inpatient setting. Future success will require CDI across the care continuum Mitigate the financial risks associated with deficient clinical documentation, over or under-coding and billing and medical record deficiencies. Ensure readiness for the increased regulatory environment Risk Adjustment Factor alignment with patient acuity and severity Identification of patients for inclusion in population health initiatives Ultimately improved. Communication between providers Patient care and outcomes Patient satisfaction 2014 Nuance Communications, Inc. All rights reserved. 35
36 What is Risk Adjustment? Risk Adjustment is a form of case mix index used for predictive modeling. A corrective tool used by actuaries to level the playing field regarding the reporting of patient outcomes, adjusting for the differences in risk among specific patients. An actuary is a business professional who analyzes the financial consequences of risk. Actuaries use mathematics, statistics, and financial theory to study uncertain future events, especially those of concern to insurance to manage financial risk Nuance Communications, Inc. All rights reserved
37 Why is Risk Adjustment Important? It s a necessary tool for Managed Care Programs Account for changes in severity & case mix over time Accurately set performance targets (quality & efficiency) Provide incentives to enroll high-cost individuals into managed care programs by ensuring health plans/acos have the resources needed to provide efficient and effective treatment It s prominent Risk adjustment payment methodologies are used across a variety of government (Federal & state) private & commercial insurance programs It s relevant Risk adjustment is an important element in VBP It s here to stay! 2014 Nuance Communications, Inc. All rights reserved. 37
38 How Prominent is Risk Adjustment? Risk adjustment payment methodologies are used across a variety of government (Federal & state) private & commercial insurance programs The Four Prominent Systems: Ambulatory Care Groups (ACGs) (John Hopkins) Chronic Illness and Disability Payment System (CDPS) (Managed Medicaid) Diagnostic Cost Groups (DxCGs) Hierarchical Condition Categories (HCCs) CMS HCCs (Managed Medicare) HHS HCCs (Managed Commercial in Health Insurance Exchange) 2014 Nuance Communications, Inc. All rights reserved. 38
39 What are HCCs? HCCs are diagnostic categories assigned based age, gender, eligibility status (age, disabled, end stage renal disease, PACE) and the ICD-9-CM diagnosis codes from encounter claims to assign patients to different "categories." The categories are designed to "bucket" patients that are not only clinically similar but follow similar cost patterns to predict future healthcare costs Nuance Communications, Inc. All rights reserved. 39
40 Where should you begin? Determine scope & depth of opportunity Varies based on patient population/insurance type & contracts Medicare Does your organization offer their own Medicare Advantage Plan? (aka Medicare HMO ) (Full risk contract!!) Do your employed physicians receive incentives from Health Plans with a Medicare Advantage Plan if they improve risk scores? Is your facility part of a Accountable Care Organization (ACO)? Commercial Health Insurance Exchange Members Does your organization receive incentives from Health Plans within the Commercial HIE if they improve risk scores? Medicaid Does your state utilize a risk adjustment methodology for Medicaid patients? 2014 Nuance Communications, Inc. All rights reserved. 40
41 Start with your Inpatient Admissions. What insurance types are the CDS actively reviewing? Traditional Medicare only? Your own Medicare Advantage members? Medicare Advantage members from other health plans treated by employed providers? Your own ACO members? Commercial Health Insurance Exchange members? Managed Medicaid? You will need to take of your DRG hat Learn and apply the correct methodology Educate the key stakeholders; providers, CDS, coders & HIM Consider how you will improve risk score across the care continuum Stay up to date with risk adjustment changes Methodology & rates, code sets, coding guidelines 2014 Nuance Communications, Inc. All rights reserved. 41
42 .then capitalize on the opportunities in the ambulatory setting Assessment Documentation, Coding, Billing, Medical Record Deficiencies Education Based on methodology(ies) in your organization CMS-HCCs, HHS-HCCs, CDPS, etc. Acceptable settings & nuances Acceptable provider types Based on the opportunities identified Diagnosis, member or provider level In general or result of assessment CDI Program Implementation Tailored to the setting & prioritized by opportunity Deploy technology & tools to handle the volume Data Analytics Create, utilize, validate or enhance 2014 Nuance Communications, Inc. All rights reserved. 42
43 2014 Nuance Communications, Inc. All rights reserved. 43
44 Ambulatory CDI Value Supports the delivery of quality of patient care by ensuring a complete and accurate medical record. Ensures complete, accurate, and compliant clinical documentation that supports the medical necessity and appropriateness of services provided. Promote complete, accurate, and compliant assignment of codes based on clinical documentation evidenced in the medical record Nuance Communications, Inc. All rights reserved. 44
45 Ambulatory CDI Value Promotes complete, accurate, and compliant billing practices. Improve documentation to proactively defend against claim denials and adverse audit outcomes. Improve documentation to reflect accurate quality and utilization reporting Nuance Communications, Inc. All rights reserved. 45
46 Ambulatory CDI Value Improve documentation for Value-Based and Risk Adjusted Payment methodologies. Improve policies, procedures, and workflows that promote compliant practices and operational excellence Nuance Communications, Inc. All rights reserved. 46
47 Implications for CDI/HIM Leaders As patient care shifts to the ambulatory/outpatient setting, CDI/HIM leadership responsibilities may expand as well. Due to historical inpatient focus of CDI/HIM, ambulatory settings are in desperate need of CDI/HIM expertise. Physician offices are especially in need of information governance assistance by HIM leadership. This is an opportunity to expand your skill set and extend your knowledge in an area you may not be unfamiliar with Nuance Communications, Inc. All rights reserved. 47
48 Summary To position our organizations for future success, CDI efforts cannot stop at the walls of the acute care setting. Ambulatory CDI cannot be simply mirrored after inpatient CDI. Analyze your data to identify risks and opportunities. Be strategic in where you start, customize your approach to fit the setting and achieve objectives, and stay focused. Optimize the use of all available technology to effectively capture complete and compliant documentation at the point of care, and efficiently manage the volume of encounters in the ambulatory setting. Perform ongoing data analysis and monitoring to maintain success and proactively address new issues as they arise Nuance Communications, Inc. All rights reserved. 48
49 Thank you 2014 Nuance Communications, Inc. All rights reserved.
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