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Development of Ambulatory CDI at Christiana Care Hospital
Karen Frosch, CCS, CCDS, CRC, CPHQCDI Project ManagerChristiana CareNewark, DE
Susan A. Carrier, RN, BSN, MBA, CCDS, CPCAmbulatory CDI Program ManagerChristiana CareNewark, DE
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Learning Objectives
• At the completion of this educational activity, the learner will be able to:
– Illustrate the timeline and support required for an ambulatory CDI program
– Demonstrate the CDI process
– Demonstrate tools needed
– Illustrate queries utilized
– Provide examples of tools to leadership and resultant trends
2018 Copyright, HCPro, a brand of Simplify Compliance LLC. All rights reserved. These materials may not be copied without written permission.
3
Christiana Care Health System – Who We Are
• 150+ patient and family advisors
• Outpatient visits: 582,257
• Home healthcare visits: 312,537
• 22nd in U.S. admissions: 53,259
• 28th in U.S. surgeries: 39,102
• 21st in U.S. ED visits: 197,340
• 31st in U.S. births:6,545
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Christiana Care Health System – Who We Are
Our major facilities include• Christiana Hospital and SurgiCenter
913 bedsOnly Level I trauma center on the East Coast corridor between Baltimore and PhiladelphiaTeaching hospital
• Wilmington Hospital and SurgiCenter241 bedsTeaching hospital
• Middletown freestanding emergency department• 16 primary care practices• 3 resident site practices• > 50 specialty and/or provider‐embedded practices• Independence at Home (IAH)
700 patients
2018 Copyright, HCPro, a brand of Simplify Compliance LLC. All rights reserved. These materials may not be copied without written permission.
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Recognizing the Need
• Contract negotiations with our Medicare Advantage plans identified low risk scores for our patient population
• Administration realized the need to capture HCCs at the time of the patient’s visit and turned to our inpatient CDI program for guidance on how to implement CDI in our ambulatory/primary care practices
• Establish the goals and scope of the program
– HCC capture only?
– E/M levels and HCCs?
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Where/How to Begin?
Learn & understand:
What HCCs/risk adjustment are
Documentation required to support HCCs
Coding rules guiding the capture of HCCs
• Many organizations are offering courses, education modules, etc. on HCCs
2018 Copyright, HCPro, a brand of Simplify Compliance LLC. All rights reserved. These materials may not be copied without written permission.
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Inpatient CDI vs. Outpatient CDI
Similarities Differences
Capturing documentation concurrently Provider workflows
ICD‐10 diagnosis specificity is the same Outpatient coding rules vs. inpatient coding rules
Metrics are needed Metrics similar to inpatient but HCC‐focused
Query process needed
Physician communication/education is essential
Physician champion is essential
Administration support is essential
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Inpatient CDI With an Outpatient Twist
• Become familiar with the primary care office routine
– Establish contacts/champions
– Understand provider documentation workflow
• It may not be the same for everyone
– Determine how to educate and communicate with providers
• This is a new concept – a lot of education and feedback is essential
2018 Copyright, HCPro, a brand of Simplify Compliance LLC. All rights reserved. These materials may not be copied without written permission.
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Query Process
• Draft a query process
– Work with providers to establish what works for them
• Be prepared to tweak the process
– Queries must be compliant and follow AHIMA/ACDIS guidelines
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Metrics
• Determine what metrics will demonstrate a return on investment – understanding risk score reporting is not timely
– # of reviews, queries, HCCs captured, etc.
• Establish a mechanism for capturing metrics
– Electronic vs. Excel spreadsheet
2018 Copyright, HCPro, a brand of Simplify Compliance LLC. All rights reserved. These materials may not be copied without written permission.
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Hire a CDI Specialist
• RN vs. coder vs. both
– This is not an entry‐level position
– Depends on scope and goals of program
– Excellent communication skills a must
– Clinical and coding knowledge required
• Develop the CDI specialist workflow
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Ambulatory CDI Specialist Evolution
2018 Copyright, HCPro, a brand of Simplify Compliance LLC. All rights reserved. These materials may not be copied without written permission.
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Ambulatory CCHS Goal = Collaboration
• Ensure complete documentation of findings, diagnoses, and treatment in the patient health record, thereby improvingthe CCHS Risk Adjustment Factor Score over the baseline score for our Medicare Advantage patient population (Medicare in NJ practices and homecare), through collaborationwith our primary care providers that reflects the severity of illness and supports accurate ICD‐10‐CM diagnosis capture
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Implementation
• Create list of Medicare Advantage patients with upcoming appointments to family medicine practitioners in Delaware practices, Medicare in NJ, and Independence at Home
• Pre‐encounter documentation review of prior 1–2 years with attention to potential chronic condition gaps
• Generate provider query with supportive documentation of potential missed or unspecified chronic conditions prior to encounter
• Post‐encounter documentation review for query response
• Correction of bill to capture corrected documentation if not completed by the provider
• Data entry in Excel worksheet for each medical record reviewed
2018 Copyright, HCPro, a brand of Simplify Compliance LLC. All rights reserved. These materials may not be copied without written permission.
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The Query Process: Electronic Query
© 2018 Christiana Care Health Services, Inc., All rights reserved
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The Query Process: Templates
• Depression• BMI• Medication indication• Prior year diagnoses• Chronicity• Ruled in/out• Respiratory• Diabetic manifestations• Dependence• Pressure injury• Diabetes with neurological complications• Hepatitis• Acute vs. history• Diabetes with retinopathy• Wet versus dry AMD• Documentation clarification (generic)
2018 Copyright, HCPro, a brand of Simplify Compliance LLC. All rights reserved. These materials may not be copied without written permission.
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The Query Process: Compliance
• Documentation clarification is required to meet accuracy in coding and severity of illness reflection for your patient …
• … If clinically appropriate and you are monitoring, evaluating, assessing, and treating, please address in your assessment and add to your charge.
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The Query Process: Top Queries
2018 Copyright, HCPro, a brand of Simplify Compliance LLC. All rights reserved. These materials may not be copied without written permission.
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Recording the Data in Excel
Review Date
Reviewer
Patient name
Date of birth
Appointment
Payer/payer comments
Location
Provider
Comments
Query needed
Query
HCC
HCC coefficient
Follow‐up date
Response
Correct code
Correction completed
Necessary follow‐up
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Monthly KPI to Leadership: Overview
• Payer RAF change over time• Program success:
‐Response rate‐Projected RAF/$ capture‐Missed opportunity RAF/$
• Coding errors, RAF/$ • Unsupported codes• Top queries
2018 Copyright, HCPro, a brand of Simplify Compliance LLC. All rights reserved. These materials may not be copied without written permission.
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Monthly KPI to Leadership: By Site and Provider
• High volume practices• Query rate
Program success at site level: ‐Response rate‐Projected RAF capture ‐Missed opportunity
• Coding errors • Unsupported codes
May‐18
# of charts
reviewed
# reviewed charts needing queries
total # of queries
queries lost 2/2 Canceled encounter/AWV
Total queries for
patients seen
# of HCC queries
# of Affirmati
ve response
Response Rate
# incorrect codes
RAF Captured
RAF missed
58 30 50 10 40 40 34 85.0% 7 6.004 1.688
23 15 20 7 13 13 2 15.4% 1 0.448 3.446
177 82 135 26 109 109 84 77.1% 23 21.029 9.088
5 2 7 0 7 7 0 0.0% 0 0.000 1.906
7 5 10 1 9 9 7 77.8% 2 2.354 0.637
48 22 39 8 31 31 20 64.5% 2 3.599 3.07
11 6 10 1 9 9 3 33.3% 1 0.736 1.754
13 5 7 2 5 5 2 40.0% 1 0.486 1.379
38 24 33 8 25 25 20 80.0% 2 6.051 1.373
43 25 34 5 29 29 25 86.2% 8 3.790 1.749
53 25 36 9 27 27 19 70.4% 6 5.144 4.059
28 10 16 5 11 11 9 81.8% 0 2.827 0.733
16 11 17 4 13 13 8 61.5% 8 2.082 1.904
17 10 15 6 9 9 2 22.2% 1 0.118 4.423
4 3 4 1 3 3 2 66.7% 1 0.118 0.660
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Trends From KPI
2018 Copyright, HCPro, a brand of Simplify Compliance LLC. All rights reserved. These materials may not be copied without written permission.
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Trends From KPI
• Higher volume of queries in first quarter• More charts reviewed at year end
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Trends From KPI
• Higher volume of queries in first quarter• Less overall queries as concept accepted
(learning curve)
2018 Copyright, HCPro, a brand of Simplify Compliance LLC. All rights reserved. These materials may not be copied without written permission.
25
Implementation: Other Needs
• Collaborate with physician champions to ID potential solutions to provider workflow obstacles
• 1:1 provider collaboration with CDI specialist at site
• Documentation tips
• Depression
• History vs. current
• The “Z” code
• DM and BMI
• Quality Corner of monthly medical group provider newsletter
• What is an HCC/RAF?
• Depression
• History vs. current
• M.E.A.T.
• Functional quadriplegia
• Peer‐to‐peer support from physician champions
• New provider training – biweekly (inpatient and outpatient)
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Documentation Tip Examples
© 2018 Christiana Care Health Services, Inc., All rights reserved
2018 Copyright, HCPro, a brand of Simplify Compliance LLC. All rights reserved. These materials may not be copied without written permission.
27
Documentation Tip Examples
© 2018 Christiana Care Health Services, Inc., All rights reserved
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Documentation Tip Examples
© 2018 Christiana Care Health Services, Inc., All rights reserved
2018 Copyright, HCPro, a brand of Simplify Compliance LLC. All rights reserved. These materials may not be copied without written permission.
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Documentation Tip Examples
© 2018 Christiana Care Health Services, Inc., All rights reserved
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Captain Horatio Chronic Condition (HCC)
Morbid obesity .365
Exudative AMD .335
ETOH dependence .420
? cirrhosis .399? malnutrition .713
Ascites (? CHF; portal HTN) .368
COPD .346
Chronic respiratory failure .302
Total RAF 4.633
with vascular .368DiabetesAmputation .586
© 2018 Christiana Care Health Services, Inc., All rights reserved
2018 Copyright, HCPro, a brand of Simplify Compliance LLC. All rights reserved. These materials may not be copied without written permission.
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Obstacles
• Ambulatory/outpatient CDI programs are uncharted ventures nationally with few resources
• One CDS (until 9/2017), 18 family medicine sites
• Risk adjustment and CDI learning curve for the primary care practices
• Compliance and legal department (fear of upcharging)
• Transitioning to a new EMR (CCHS using 2 EMRs during transition)
• Measurement of actual success due to CMS lag in diagnosis verification (data collection applied to “projected” analysis)
• Providers code their own charts
– Incorrect codes
• Diagnosis does not match documentation
• Diagnosis addressed with insufficient MEAT
• Coding guidelines not followed (clinical culture vs. coding awareness):
‐Diabetes link to complication
‐History vs. acute/active conditions
‐Lack of specificity
– Delayed claim submission (5‐calendar‐day submission window from date of encounter)
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Lessons Learned
• Ability to adapt to the variability of documentation workflow from provider to provider is key for optimal query response.
• Continued feedback, engagement, and education with the providers is critical to successful outcomes.
• Clinical leadership support continues to be essential to provider buy‐in.
• Ambulatory/outpatient CDI programs are uncharted ventures nationally, so there are few resources on which to base program implementation.
• Because actual risk scores are only reported once a year, it is difficult to measure actual success, so you need to demonstrate success in other ways. Data collection and analysis is important.
2018 Copyright, HCPro, a brand of Simplify Compliance LLC. All rights reserved. These materials may not be copied without written permission.
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Path Forward
• Introduction of HCC dashboard in EMR
• New workflow for clinical documentation department and providers
• Ambulatory CDS electronic worksheet development for tracking and reporting
• Expansion of CDS support to specialty practices (cardiovascular, endocrine, etc.)
• Learning curve promotion and program excellence to ACO members
• Billing cycle closure with process for denial analysis and resultant education to the provider
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Thank you. Questions?
Karen Frosch ‐ [email protected] Carrier ‐ [email protected]
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.
2018 Copyright, HCPro, a brand of Simplify Compliance LLC. All rights reserved. These materials may not be copied without written permission.