ACDIS day2-3 track3-5 pres 0516-Newell Wood-G-f · PDF file• Episode payment initiatives ... >70thand60thand50thand40thand

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George Wood, MDSpecialty Consultant

Shannon Newell, RHIA, CCSDirector Quality Initiatives

Enjoin

Engage Your Orthopedic Surgeons in CDI: New CMS Initiative Links Quality Outcomes to Hospital and Physician Reimbursement

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• At the completion of this educational activity, the learner will be able to:

– Understand key concepts associated with the Comprehensive Care Joint Replacement Payment Model (CJR)

– Describe key aspects of the “THA/TKA Risk Standardized Complication Rate,” which impacts CJR payment

– Recognize the impact of documentation and code assignment on CJR measure performance

Learning Objectives

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• Move away from payment for volume

• Improve care coordination

• Promote alignment of financial and other incentives to increase the quality of care and lead to better outcomes

BackgroundCMS Transition to Value‐Based Payments

HHS Secretary Burwell Posting January 2015

Goals: Increase % of Medicare provider payments in alternative payment models that tie payment to how well providers care for patients• 30% by 2016• 50% by 2018

• Hospital pay‐for‐performance programs

• Merit‐based incentive payment system

• Innovation models portfolio • Accountable care

organizations• Episode payment initiatives• Primary care

transformation• Medicaid, CHIP initiatives• Accelerate testing of new

models• Speed adoption of best

practices


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Description• A payment model that bundles the payment for all services

provided to a THA/TKA patient • Mandatory – 67 Metropolitan Statistical Areas (MSAs)

Population

• Fee‐for‐service Medicare• Lower extremity replacement or reattachment procedures

(MS‐DRGs 469 or 470) (“anchor MS‐DRGs”)• Includes fractures

Episode duration• Begins with inpatient hospitalization for procedure • Ends 90 days after hospital discharge • Includes the costs of most services within the 90‐day period

Financial risk• Hospital is accountable party and bears all financial risk • Hospital can share in savings and/or have a repayment• Hospital can share risk and gains with “collaborators”

Effective date• Begins April 1, 2016 • Give year test period ends December 31, 2020• May be extended

Estimated FFS Medicare savings: $343 million (2.8% expenditures)

Comprehensive Care Joint Replacement Payment Model (CJR) – Overview

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• Fee‐for‐service “as usual”

• Annual reconciliation process to compare “costs” to “target price”

• Target price

– Phased in hospital‐specific/regional costs using 3 years of historical data

– Pricing adjustment for MS‐DRG 469 vs. MS‐DRG 470

– Pricing adjustment for hip fractures (70% increase in costs)

– CMS “discount” of 3%

Performance year

Year 1Apr–Dec2016

Year 2 CY 2017

Year 3 CY 2018

Year 4CY 2019

Year 5 CY 2020

Hospital blend % 66% 66% 33% 0% 0%

Baseline year 2012–2014 2012–2014 2014–2016 2014–2016 2016–2018

CJRPayment Methodology

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Abovetarget price

Quality composite score

Abovetarget price

Performance year episode cost reconciliation

Hospital repayment

Hospital reconciliation payment

Belowtarget price

The quality composite score determines • Eligibility to receive reconciliation payment• Amount of repayment, or reconciliation

payment, through a reduction in the CMS discount %

CJRQuality Composite Impact on Payment


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CJRQuality Composite Score – What’s in There?

• THA/TKA Risk Standardized Complication Rate (RSCR)

– Redundant use of Hospital Value‐Based Purchasing Program measure

– Represents 50% of quality composite score

• Patient satisfaction surveys

– Redundant use of Hospital Value‐Based Purchasing Program measure

• Patient‐reported data

– Submission of data elements for CMS development of risk adjusted measure

%ile rank THA/TKA comp points Patient exp points PRO data subm points

> 90th 10.00 8.00 2.00

> 80th and < 90th 9.25 7.40 2.00

> 70th and < 80th 8.50 6.80 2.00

> 60th and < 70th 7.75 6.20 2.00

> 50th and < 60th 7.00 5.60 2.00

> 40th and < 50th 6.25 5.00 2.00

> 30th and < 40th 5.50 4.40 2.00

< 30th 0 0 2.00

Improvement 1.0 .80 N/A

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What it is• Risk‐adjusted measure to estimate the rate of defined

complications with elective primary THA and TKA measure in

Population (cohort)• Fee‐for‐service Medicare• ICD‐10 procedure driven (total hip, total knee)• Excludes fractures, partial hips, patients with neoplasms, …

Financial risk

• Impacts CJR Quality Composite Score• Impacts Clinical Outcomes Domain Score in HVBP

Complication Time frame for occurrence

AMI Within seven days of index admission admit date

Pneumonia Same as above

Sepsis/septicemia/shock Same as above

Surgical site bleeding During index admission or within 30 days of admit date

Death During index admission or within 30 days of admit date

Mechanical complications During index admission or within 90 days of admit date

Peri‐prosthetic joint/wound infection Same as above

Risk Standardized Complication Rate (RSCR) Overview

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• Cohort excludes discharges with any of the following with concurrent THA/TKA

QualifierICD‐10 code field(index adm only)

Fracture – femur, hip, pelvic PDx or SDx

Mechanical complication PDx

Malignant neoplasm – pelvis, sacrum, coccyx, lower limbs, or bone/bone marrow, or a disseminated malignant neoplasm

PDx

Partial hip arthroplasty (PHA) Px

Resurfacing procedures Px

Revision procedures Px

Removal of implanted devices/prosthesis Px

Transfers from another acute care facility N/A

ExclusionsICD‐10 code field(index adm only)

> 2 THA/TKA procedure codes Px

Discharged AMA N/A

RSCRCohort Exclusions


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ID discharges in cohort

ID actual observed complications

Risk adjust cohort

(CMS) predicted/expected

12‐month “lookback.” Part A & B claims. “Complications.”

Key takeaway: All discharges in the cohort “count” in the measure, even if there was not a complication

RSCRRisk Adjustment Methodology

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16.99%

7.65%

6.62%

4.82%

3.65%

2.96%

2.89%

2.38%

2.20%

0.00% 2.00% 4.00% 6.00% 8.00% 10.00% 12.00% 14.00% 16.00% 18.00%

MALNUTRITION…

OBESITY…

ESRD_DIALYSIS…

Athero

PNEUMONIA

RENAL_FAILURE

PARALYSIS_FUNCTDIS…

CARDIO_RESPIRATORY…

VASDIS_WCOMP…

RHEUMATOID_ARTHRITIS or…

VERTEBRAL_FRACTURES

Other congenital deformity of hip (joint)…

Osteoporosis and other bone/cartilage…

Osteoarthritis of hip or knee

PLEURALEFFUSION

Comorbid category group risk adjustment impactTHA/TKA complications

“Malnutrition” “Cachexia”

“Morbid obesity”

RSCRRisk Adjustment Methodology

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• CJR cohort: MS‐DRG 469‐470 (with fractures); RSCR = ICD‐10 PCS total hip/knee

• CJR cohort: With fractures; RSCR = qualified without fractures +

• CJR cohort: Inpatient & outpatient; RSCR = inpatient only

The Big Picture“THA/TKA” – A Mixed Bag

• Old MI • COPD

• CAD • Hypoxemia

• Chronic respiratory failure

• “Chronic” renal insufficiency

CJR(costs)

RSCR(complications)

Satisfaction(HCAHPS)

Patient‐reported outcomes


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CDI Opportunities – RSCR

• Measure specifications – CDI vulnerability analysis

Measure impact Data quality variable CDI vulnerability

Cohort inclusion ICD‐10‐PCS code Low

Cohort qualifier Neoplasms Medium (“PMH”)

Cohort qualifier Partial hip replacement Low

Cohort exclusions AMA Low

Complications “AMI” Medium (“demand ischemia”)

Risk adjustment Old MI High (documentation)

Risk adjustment CAD High (documentation)

Risk adjustment Chronic respiratory failure High (documentation)

Risk adjustment Chronic renal insufficiency High (documentation)

Risk adjustment Osteoarthritis Low

…

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CDI Opportunities – CJR

• Measure specifications – CDI vulnerability analysis

Measure impact Data quality variable CDI vulnerability

Cohort inclusion MS‐DRG 469/470 –Principal diagnosis

Low

Cohort inclusion MS‐DRG 469/470 –Procedure

Medium (root operations – removal, replacement, supplement, revision)

Target pricing Fracture capture Low

Target pricing MCC capture High (documentation)

Target pricing Excluded costs Medium

….

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• Root operation selection impact on MS‐DRG assignment

CDI Opportunities – CJRProcedure Code Assignment

MS‐DRG MS‐DRG description Replacement Removal and replacement

Revision

469/470

Major joint replacement or reattachment lower extremity

466/467

Revision of hip or knee replacement


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CDI Opportunities – CJRRoot Operation – Revision

• Correcting, to the extent possible, a malfunctioning or displaced device

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CDI Opportunities – CJRRoot Operation – Replacement

• “Putting in or on biological or synthetic material that physically takes the place and/or function of all or a portion of a body part. A body part may be taken out and/or replaced, physically eradicated, or rendered nonfunctional during the procedure. A removal procedure is coded for taking out the device used in a previous replacement procedure.”

Physician terminology includes “arthroplasty”

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CDI Opportunities – CJRRoot Operation – Removal

• Taking out device from a body part


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Case Study Billed MS‐DRG 470 (Replacement)

Full text in your e‐handout

Diagnosis: “Septic L Total Knee”

Clinical History:

• 65 yo WM

• 2 years ago – S/P revision TKR 2/2 component loosening

• 12 mo ago – I&D L knee for acute septic left knee

• 2 mo ago – explantation of total left knee

• Current admission – for removal of antibiotic spacer, repeat I&D, placement of L total knee prosthesis

Procedures:

• “I&D L total knee”

• “Removal of L knee antibiotic spacer”

• “Complete revision of L total knee to hinged total knee prostheses”

• Quadriceps snip and repair

• Application of incisional wound vac dressing less than 50 sq cm

MS‐DRG: 470

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0SRD0J9, Replacement, left knee joint, open, synthetic substitute, cemented

CDI Opportunities – CJRRoot Operation – Replacement (cont.)

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Case Study Billed MS‐DRG 470 (Replacement) (cont.)


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• Correct root operation given physician terminology “revision”?

• Why MS‐DRG 470 (replacement) instead of MS‐DRG 469 (revision)?

Procedures:

• “I&D L total knee”

• “Removal of L knee antibiotic spacer”

• “Complete revision of L total knee to hinged total knee prostheses”

• Quadriceps snip and repair

• Application of incisional wound vac dressing less than 50 square cm

FY 2016 IPPS final rule – p. 49390


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• The impact of correct principal diagnosis selection

Diagnosis: “Septic L Total Knee”

Clinical History: 65 yo WM. 2 years ago – S/P revision TKR 2/2 component loosening. 12 mo ago – I&D L knee for acute septic left knee. 2 mo ago – explantation of total left knee. Current admission – for removal of antibiotic spacer, repeat I&D, placement of L total knee prosthesis

Principal diagnosis MS‐DRG (description)

Aftercare following explantation of knee joint prosthesis (Z47.33)

470 (Major joint replacement or reattachment of lower extremity w/o MCC)

Infection and inflammatory reaction due to internal left knee prosthesis, subsequent encounter (T84.54XD)

941(OR procedure with diagnoses of other contact with health services)

Infection following procedure, initial encounter (TT81.4XXA)

857(Postoperative or post‐traumatic infections with OR procedure)

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Clinical PointsRevision Outcomes

• Revision surgery for a previous total joint arthroplasty

– > 30% 5‐year mortality

– 10‐fold risk of complication compared to a primary total joint


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Case StudyFull Text in Your E‐Handout (cont.)

• Summary

– All “revisions” noted by the surgeon are not revisions

– The common staged procedure for treatment of an infected joint (hip or knee) must be coded as a “replacement”

– Replacement + removal (of hardware) should group to the MS‐DRG for revision

– The removal of only a “spacer” appears to result in a grouping error with assignment to the MS‐DRG for replacement

– This will affect MS‐DRG assignment and the volume of cases in the CJR

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Presentation SummaryKey Takeaways

• Documentation and reported codes impact CJR performance through:

– The selection of discharges included in the CJR and the RSCR

– Target pricing through the capture of fractures and MCCs

– Costs included in the 90‐day bundle

– The selection of discharges included in the RSCR

– The reporting of complications included in the RSCR

– The risk adjustment of discharges included in the RSCR

• Physicians will likely assume the role of CJR “collaborators” and thus share in CJR financial risks

• CDI programs need to identify and address opportunities to promote and support the capture of impactful documentation, and accurate reported codes, across the inpatient and ambulatory setting for the CJR population

• Educational of organizational leadership on the need to engage the CDI program in CJR preparation and monitoring initiatives is likely required

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Thank you. Questions?

[email protected]@enjoincdi.com

In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section at the front of the program guide.

CJR MS-DRG 470 Case Study

Billed MS-DRG: 470

PREOPERATIVE DIAGNOSIS: Septic left total knee.

POSTOPERATIVE DIAGNOSIS: Septic left total knee.

PROCEDURES:

1. IRRIGATION AND DEBRIDEMENT, LEFT TOTAL KNEE.

2. REMOVAL OF LEFT KNEE ANTIBIOTIC SPACER.

3. COMPLETE REVISION OF LEFT TOTAL KNEE TO HINGED TOTAL KNEE PROSTHESIS.

Discussion points:

This is not a Revision in terms of root operation in ICD10. If this procedure is coded as

0SWD0JZ, Revision of Synthetic Substitute in Left Knee Joint, Open, this causes an erroneous

DRG shift to 468, Revision of hip or knee replacement

See correct code assignment at end of the op note

4. QUADRICEPS SNIP AND REPAIR.

5. APPLICATION OF INCISIONAL WOUND VAC DRESSING LESS THAN 50 SQUARE CM.

OPERATIVE FINDINGS: Wound was found to be clean with clear straw pink-tinged colored serous fluid. Antibiotic spacer components were found to be well fixed and did take the time to remove these from the femur and tibia and to try and prevent any fractures. Because of the stiffness of the knee, a quadriceps snip was performed and repaired to allow for additional exposure. The hinge prosthesis was found to be stable full extension and flexion to 90 degrees at the end of the case.

COMPLICATIONS: None.

SPECIMENS: Fluid and tissue sent for culture.

COMPONENTS USED: Stryker hinged total knee system using a size medium MRH left knee hinged femoral component with a size medium to MRH knee tibial baseplate. There was a 13 x 155 mm fluted stem extension on the femur with a 10 mm medial and lateral distal femoral augments with a 40 mm stem extender on the tibial component, a 13 mm polyethylene tibial insert was used for hinge rotating component. Simplex antibiotic cement was used. A tibial component was fully cemented. The femoral component was press-fit stem cemented distally.

CLINICAL HISTORY: The patient is a 65-year-old, white male, who is status post revision total knee replacement for component loosening in October 2011. He subsequently underwent irrigation and debridement of left total knee for acute septic left total knee in December 2012, did well for 18 months, and then presented with acute on chronic infection just over 2 months ago. At that time, he had an explant of left total knee and placement of an antibiotic spacer. He now presents for removal of antibiotic spacer, repeat irrigation and debridement and placement of a left total knee prosthesis using a hinged component. The patient had been off antibiotics for


2 weeks. We had aspirated his knee in the office with no organisms within the fluid. He now presents for definitive procedure.

OPERATIVE PROCEDURE: The patient was brought to the operating room and a general anesthetic was given by the anesthesia staff. At all times during procedure, patient's head and neck protected by the anesthesia staff. The patient was placed in supine position. All bony prominences were identified and well padded. Left lower extremity prepped and draped in usual sterile orthopedic fashion. Time-out was performed to identify correct patient, procedure, and operative site. Left lower extremity was exsanguinated using an Esmarch. Tourniquet was inflated to 300 mmHg. A longitudinal incision centered over the previous incisional scar in the left knee was made sharply with a knife and carried down through skin, through subcutaneous tissue. Great care was taken to dissect sharply down to make a thick cutaneous skin flaps to allow for additional exposure medial and lateral gutter flaps were made. The knee was then

aspirated using 18-gauge needle and clear pink colored straw fluid was aspirated1. This was

sent for culture. The medial parapatellar approach in the knee was utilized. The patella was

subluxed and the knee was flexed. A complete synovectomy was performed2, part of this

capsular tissue was sent for culture. The knee was felt to be clean. Attention was then turned towards increasing flexion and allowing for more exposure. Because of the tightness of the exposure, a quadriceps snip was made making a diagonal incision 4 cm proximal superior pole of patella across the quadriceps. This allowed for additional exposure of the components.

Using combination of flexible and rigid osteotomes and a bone tamp and mallet, the femoral

antibiotic spacer prosthesis was removed from the bone3. There was noted to be a fibrous union

of the previous medial upper condyle fracture. Osteotomes were used to remove the cement on the distal femur and the femoral cement plug was also removed. There was a marked amount of bone loss within the metaphysis heel portion of the distal femur. There was still some good remaining bone both the medial and lateral condyles to allow for end loading. Attention was then turned to the tibia. An osteotome was used to remove the cemented tibial tray antibiotic spacer. This was also found to be well fixed to the tibia. Care was taken to prevent any fractures. There was found to be anterior medial defect of about 2 x 1 cm of the anterior medial cortex of the tibia. The cement was also removed. Attention was turned towards the femoral canals and uterine curettes were used to debride both the femoral and tibial canals. The knee was then copiously irrigated with four 3 L bags of normal saline, second bag containing Betadine infusion. Attention was then turned towards placing of the trial components. The tibia was reamed up to a size 12 reamer. The tibial cutting block using intramedullary guide was placed and pinned. A clean-up cut on the tibia was made of about 2 mm in thickness. The clean-up down to good healthy bone. Care was taken to protect the patellar tendon and collateral ligaments. A size medium to tibial base plate was selected with a 40 mm stem extender. The tibia was found to be void of most metaphysis heel bone. There was a good shell of bone from the cortex. The base plate was found to fit well. Attention was turned to the femur which was reamed up to a size 13 mm and a depth of 155 mm. Distal femoral clean-up resection was made, removing about 2 to 3 mm of bone. The femur was sized for a medium hinged femoral component. The 4 in 1 cutting block for the femoral component was placed and the appropriate cuts were made. The large posterior chamfer cuts were performed. Plan was for 10 mm medial and lateral distal femoral


augments. A trial component for the femur was then placed, size medium with a 10 mm medial and lateral distal femoral augments and a 13 mm stem. This was found to have a good fit. There was still a void bone in the metaphyseal region, but otherwise good and bearing bone. A trial 13 mm tibial insert was placed. Knee was taken into full extension, flexion up to 90 degrees. Attention was then turned to the patella and the cement cap on the patella was removed with an osteotome, a clean-up cut was used using a sagittal saw, there still remained a good patellar thickness. The patella was drilled for an asymmetric 35 mm patellar button. Trial button was placed. Knee was taken through range of motion and found to have a good patellar tracking. A small lateral release having been made. The knee was then again copiously irrigated. Plan were cementing in 2 stages. The tibial component was cemented into the proximal tibia, fully cemented with the distal cement plug. This was placed on proper amount of external rotation. The patellar component was also cemented at the same time. Excess cement was removed. Cement was allowed to harden. Attention was then turned to the distal femur and the femoral component was press fit and distally cemented, excess cement was removed, cement was allowed to harden. The knee was then trialed with a 13 mm insert. This was found to be the appropriate thickness with good working hinge mechanism. The final hinged components including the polyethylene of the tibial post and bearings were placed with a 13 mm tibial insert. Once all components were in and locked, knee was taken through final range of motion. Full extension. No recurvatum, flexion up to 100 degrees stable with good patellar tracking throughout its range of motion. The knee was copiously irrigated. The tourniquet had been released and hemostasis was maintained. The quadriceps snip was closed with #5 fiber wire. The retinacular incision was closed with #1 PDS suture. The subcutaneous tissue closed with 2-0 PDS suture. Skin was reapproximated with staples. Incisional wound VAC dressing was placed less than 50 square cm to good suction. The patient was awakened, transferred to recovery in stable condition. There were no complications.

1. 0S9D0ZX, Drainage, left knee joint, open, no device, diagnostic

I believe this drainage was done strictly for organism culture, therefore an “X” qualifier is justified. There was likely not a therapeutic aspect to this since the intention was to completely replace the joint.

2. 0SBD0ZZ, Excision, left knee joint, open, no device, no qualifier

3. 0SPD08Z, Removal, left knee joint, open, spacer, no qualifier

4. 0SRD0J9, Replacement, left knee joint, open, synthetic substitute, cemented

Documents

ACDIS day2-3 track3-5 pres 0516-Newell Wood-G-f · PDF file• Episode payment initiatives ... >70thand60thand50thand40thand