2/1/2016. Clinical Documentation: The Key to Unlocking Your VBP Opportunity. Today s Speakers. Goals and Objectives

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1 Clinical Documentation: The Key to Unlocking Your VBP Opportunity Today s Speakers Bill Hannah, Principal Wayne Little, Partner Michelle Wieczorek RN RHIT CPHQ, Senior Manager February 2, Goals and Objectives At the conclusion of today s webinar, the participant will: Understand the importance of having a robust clinical documentation program Be introduced to the mandatory government programs impacting payment reform Understand and articulate the importance of clinical documentation in VBP and other risk adjusted alternative Payment Models Define and understand Key Process Considerations for CDI programs built for success under alternative payment models. 3 1

2 The Importance of a Robust Clinical Documentation Program Bill Hannah, Principal 4 Expanded focus on Clinical Documentation Clinical Care Reimbursement Coordination of Care Continuity of Care Complete Patient Story Foundation for Compliant Coding Consumption of Resources Risk Adjustment in both MS and APR DRG s Statutory/Regulatory Required for Licensure Accreditation Third party reviews Research Disease Tracking Comparative Data Used for Quality Improvement 5 CMS Accelerates the Timeline for Payment Tied to Quality and Value Metrics HHS goal of 30 percent traditional FFS Medicare payment through alternative payment models by the end of percent by the end of 2018 HHS Press Office % of payment tied to 70 quality and value metrics 60 (ex. Hospital Value Based 50 Purchasing, Hospital Readmission Reduction 40 Program) Traditional, Fee for Service Alternative Payment Models 2

3 Mandatory Elements Reform Timeline January 2016, hospitals and physicians are affecting performance criteria that will impact payments for 2017, 2017, 2018 and beyond 7 Clinical Documentation and Risk-Adjusted Alternative Payment Models Wayne Little, Partner 8 Key Considerations CMS uses a different DRG grouper for payment () than for alternative payment programs such as HVBP and Readmissions. Many legacy CDI Programs are focused upon capturing of secondary diagnoses that impact the only. There are many secondary diagnoses that are not classified as comorbid conditions or complications for purposes of the MS DRG assignment however, they may still have a significant impact on risk adjustment for the alternative payment programs. Many of these secondary diagnosis may go un coded even if documented if they do not impact the based upon coding norms. 9 3

4 Risk-Adjustment Attribute Intended Population Approach to Severity Maintained by 3M Medicare (age 65+ or under age 65 with disability) Secondary Diagnoses include Complications and Comorbid Conditions applied to some base DRG s to tier them into with or without CC or MCC designations. 3M TM APR DRG s Maintained by 3M and NACHRI All patient refined (based upon the Nationwide Inpatient Sample) Base DRG s each have 4 severity levels. No CC or MCC list. Instead, severity depends on both the number and the interrelationship of the secondary diagnoses. Number of DRG s 746 1,256 Newborn DRGs 7 DRG s; no use of 28 base DRG s each with 4 levels birthweight of severity (total of 112) February 2, Importance of Diagnosis Coding Depth Category Diagnosis ICD 10 Code Amputation Status, Lower Limb Status amputation, toes, foot, ankle Z below/above knee Congestive Heart Failure CHF I50.9 Pulmonary Heart Disease I27.9 COPD COPD J44.9 Emphysema J43.9 Chronic Bronchitis J42 Diabetes Diabetes, uncontrolled E11.65 Major Depressive Disorders Major Depression F32.9 Schizophrenia Schizophrenia F20.9 Vascular Diseases Peripheral Vascular Disease I73.9 Aortic Atherosclerosis I70.0 Aortic Aneurysm I71.9 Abdominal Aoristic Aneurysm I73.9 History of CABG Presence of coronary bypass graft Z95.1 Diagnosis Having the Greatest Impact in Risk Adjusted Reimbursement Programs (Mortality and Readmissions) That Are NOT a CC or MCC Under System February 2, Diagnosis Coding & Trends 12 4

5 CDI Example Patient with dysuria, fever and altered mental status: Urosepsis documented in progress notes. Lab reports showed serum creatinine and BUN levels of 4.5 & 50, respectively. Low urinary output. Physician ordered 1L of IV NS wide open with maintenance IV fluids of 150 cc/hr to follow. Serial creatinine and BUN levels declined over the next 3 days to 1.2 & 2.4, respectively. Patient maintained on Symbicort and Lipitor at home. 13 Legacy CDI Program Before 690 KIDNEY & URINARY TRACT INFECTIONS W/O MCC Relative Weight.7823 PDX Urinary Tract Infection SDX Coronary Artery Dx APR DRG 463 APR Weight.5768 SOI Level 2 Risk of Mortality 2 Expected Mortality.3% After 871 SEPTICEMIA OR SEVERE SEPSIS W MV 96+ HOURS With MCC Relative Weight PDX Sepsis SDX Coronary Artery Dx APR DRG 720 APR Weight.8206 SOI Level 2 Risk of Mortality 2 Expected Mortality 3.1% The CDI Specialist queried the physician based upon lab values and presence of SIRS Criteria to verify an alternate principal dx. of Sepsis, achieving an improved DRG and Reimbursement. 14 Future State CDI Program Before 690 KIDNEY & URINARY TRACT INFECTIONS W/O MCC Relative Weight.7823 PDX Urinary Tract Infection SDX Coronary Artery Dx APR DRG 463 APR DRG 720 APR Weight.5768 APR Weight SOI Level 2 SOI Level 4 Risk of Mortality 2 Risk of Mortality 3 Expected Mortality.3% Expected Mortality 6.3% The CDI Specialist sought clarity in the presence of COPD a secondary diagnosis not impacting the through reviewing of the medication list and noting Symbicort. The CDI Specialist also noted the presence of clinical indicators indicative of ATN; and queried the physician to clarify the diagnosis. The combination of the additional secondary diagnosis moved the SOI, ROM and Expected Mortality. After 871 SEPTICEMIA OR SEVERE SEPSIS W MV 96+ HOURS With MCC Relative Weight PDX Sepsis SDX Acute Renal Failure with ATN COPD 15 5

6 Key Performance Considerations and The Future State Requirements of CDI Programs Michelle Wieczorek, Senior Manager 16 Impacts to Legacy CDI Programs Preparing for Future State Requirements Data Analytics Collaboration Technology Operations Workflow 17 Data Management and Analytic Considerations based metrics are no longer sufficient for measuring the impact of the CDI Program on the documentation and coding processes. As a result, different metric dashboards and reports are required. An APR DRG and an is stored on all patients upon each review. (DRG Progression) Acuity Measures for SOI and ROM are stored on all patients upon each review. Reporting solution accommodates Provider, Patient and Population Centric data. 18 6

7 Sample Key Process Indicator: Coding Depth Secondary Diagnosis Capture Per IP Case Q2 Linear (Q4) Q1 Q3 Q4 19 Sample Key Process Indicator: Severity of Illness Distribution 100% 95% 90% 85% 80% 75% 70% 65% 60% 55% 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Severity of Illness Distribution for Inpatient Admissions Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q SOI 1 SOI 2 SOI 3 SOI 4 20 Technology Considerations Because the CDI Specialist is doing more reviews, assessing for severity and APR DRG impacts, and consequently creating more queries for the provider, the technology considerations for the CDI program are heightened. APR DRG Grouper is Licensed for use by CDI Specialists and Coders Software Solution Supports CDI Workflow Structured Data from CDI Solution Available for Reporting New Reporting Metrics Electronic Query Solution for Providers Integrated with EHR 21 7

8 Sample: Impact of Electronic Query Response Tool Query Response Rate within 24 Hours Cardiology Percent Query Response Tool Implemented Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q Dr. G Dr. A Dr. B Dr. C Dr. D Dr. E Dr. F GOAL 22 Workflow Considerations CDI Workflow must be adapted to accommodate deeper severity based reviews, more coaching with providers, and prioritization of cases for initial, subsequent and reconciliation reviews. The CDI Specialist has access to an encoder and a Working DRG ( and APR DRG) is assigned as part of CDI Workflow Concurrent Workflow includes Verbal Queries and Face Time with Providers Workflow is driven by worklists to aid in prioritization The Working DRG is Concurrently Available to Care Management and Quality 23 Operational Considerations Transforming the CDI Function from a legacy or focused program to a future state acuity and quality outcome program requires several operational considerations for training and staffing. The Workforce is trained and knowledgeable in Risk Adjustment There is a DRG Reconciliation Process for all DRG Mismatches CDI Peer Physician Advisor Roles are Implemented 24 8

9 Collaboration Compelling providers to improve clinical documentation can no longer be accomplished without an ongoing, systematic process which includes hospital departments combining their data and skills to support their providers. There are regularly occurring opportunities to share Provider, Patient and Population Centric reports with the Medical Staff The CDI Program and Coding Program utilize the same standard query tools There is a regularly occurring opportunity to share CDI program information with Coding, Revenue Cycle, Care Management, and Finance 25 Recommended Next Steps Think about your organizational preparedness for alternative payment methods. Is your organization ready for managing your revenue at risk? Think about how well your CDI Program is prepared for meeting the challenges of payment reform. Review the CDI Program Checklist which will be ed to you in follow up to today s presentation. Contact Information Bill Hannah, Principal Atlanta, Georgia P: Wayne Little, Partner Atlanta, Georgia P: Michelle Wieczorek, Sr. Manager Atlanta, Georgia P:

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