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Outpatient CDI Implementation, Integration,
and Issues NYHIMA 79th Annual Conference
Tuesday, June 3, 2014 Mel Tully MSN, CCDS, CDIP
ICD-10 Will Launch
NOT SURE
ANOTHER DAY
SOMEDAY
NEVER
NEXT YEAR
PERHAPS
Key Discussion Points• Current state of Outpatient CDI Programs• Background and structure of Medicare
Advantage (MA) program• CMS Hierarchical Condition Categories
(HCCs) and HCC model• Integration of current inpatient CDI and
outpatient CDI• CDI role in outpatient denials • Education for clinical documentation
specialists, coders, and providers
Current State - Outpatient CDI Program
• Hospital Outpatient– Most hospitals have implemented inpatient CDI programs, outpatient CDI has not been
a focus• Likely because hospitals are financially strapped, • Have many competing priorities, • Little to no data available on the success of outpatient CDI
– Outpatient volumes are very high and hospitals cannot afford to staff CDI programs in these areas
– Hospitals focus on Revenue Integrity functions• Medical Necessity Audits and Charge Master/Charge Capture through Revenue Integrity
Specialists with a non-clinical focus
• Physician Office– Physicians are reimbursed based on E/M and CPT codes and do not have a good
understanding of how critical clinical documentation can be to preventing denials. – E/M Auditing is a high demand services. Most physicians, whether owned or
independent have an external vendor perform an annual E/M Audit as part of their Compliance Plan. However, physicians are very price sensitive for this service.
Physician Engagement for OP-CDI
• Accurate clinical documentation is essential for quality patient care.
• Over recent years, based largely on the MS-DRG system, physicians have become aware of the impact of accurate and complete clinical documentation on physician profiles, morbidity and mortality data, and hospital reimbursement.
• With the rapid industry transition to quality-based payment, physicians have an even greater incentive to understand and assure accurate documentation.
• Many physicians are now receiving financial incentives under Medicare Advantage programs. Few understand the revenue impact of complete and accurate documentation in all clinical settings.
• With the advent of ACOs and other integration models, physicians are increasingly accepting financial risk associated with patient management.
MEDICARE ADVANTAGE AND CMS HIERARCHICAL CONDITION CATEGORIES
Medicare Advantage (MA) (Part C)
Medicare Risk Adjustment• Type of Medicare health plan– Contracts with CMS to provide benefits– Purpose of the CMS-HCC model is to promote fair payments
to MA plans that reward efficiency and encourage high quality care for the chronically ill.
• Part A and B, and oftentimes including Part D (RxHCC)– Extra dental, vision, hearing and preventive services– Some optional services such as exercise classes
• Plan receives payment for each member from CMS– Payment based on member predicted health status and
demographic characteristics• 2013 enrollment – 14.4 M (28%)
– Up nearly 10% since 2012
HCCs• HCC concept similar to DRGs• Each member (patient) has Risk Adjustment Factor (RAF)
score– Organization average RAF score similar to case mix– Score of 1 represents typical patient– Less than 1 is healthy patient– Greater than 1 likely patient utilizes greater resources
• Certain diagnoses/status increase RAF– Similar to CCs and MCCs (75% are classified as CCs/MCCs)– Usually chronic conditions—but not always– Specific documentation & coding increases the mapping
likelihood• Reported for certain encounters based on setting &
provider type
HCC Uses• Medicare Advantage Capitation
Payment• Shared Savings Program– Accountable Care Organizations• Historical benchmark expenditures adjusted
based on CMS-HCC model
• Medicare Physician Quality and Resource Use Reports
• Value Based Purchasing Initiatives (Bundled Payments)
Risk Adjustment Status• Currently payers receive most benefit• Some physicians incentivized, especially in CA• ACA is changing environment, increasing
provider stake– Accountable Care Organizations– Patient Centered Medical Homes
• Many current vendors focus on home visits to members because insufficient OP documentation
• MA plan enrollment increasing
Key Analytics for HCC CaptureWhere is HCC data collected?
• Medicare claims and encounter data• Early intervention to ensure quality clinical outcomes – HCC
CDS• Retrospective and prospective reviews including chart
audits• Health status assessment each year – ‘Patient Summary
Visit’– Monitored– Evaluated– Assessed– Treated
• Quarterly review of members to assess patient data – Health status above/below 1– Jumps in RAF scores
Physician Documentation!!
Diagnosis Sources—Provider Types
• Diagnoses documented by select provider types are appropriate for coding and reporting for MA coding.
• MD or DO– OD Doctor of Optometry– DC Doctor of Chiropractor– DDS Doctor of Dental Surgery– DO Doctor of Osteopathy– DPM Doctor of Podiatry
• All NP, CNS, PA• Therapists—except “respiratory”• LCSW/CSW Licensed Clinical Social Worker/Clinical Social
Worker• CWCN/CWOCN Certified Wound Care/ostomy Nurse
Disease Hierarchies• Address situations when:– Multiple levels of severity for a disease or
clinically related• Payment based only on most severe and costly
manifestation of disease
– Varying levels of associated costs…..are reported for the same patient
• Hierarchies are published in the Rate Announcement
Figure 2-3Clinical vignette for CMS-HCC (version
12) classification community-residing, 76-year-old woman with AMI, angina
pectoris, COPD, renal failure, chest pain, and
ankle sprain
Hierarchical Condition CategoriesRules
• Although HCCs reflect hierarchies among related disease categories, for unrelated diseases, HCCs accumulate
– For example, a male with heart disease, stroke, and cancer has (at least) three separate HCCs coded, and his predicted cost will reflect increments for all three problems.
– So unlike DRGs, there may be several HCCs assigned to an individual
Breakdown of HCC• 3033 ICD-9 codes are mapped to 87 categories
(11,312 ICD-10 CM codes)• HCC logic is imposed on certain disease groups• The HCC model is cumulative, so that a patient
can have multiple diagnoses assigned • Each diagnosis is factored into the member’s
risk profile which calculates an individual RAF score (Risk Assessment Profile)
• RAF score = “ambulatory CMI” and is calculated annually
Hierarchical Condition Categories (HCC)Why you should get to know them now
• The Medicare risk adjustment payment system uses clinical coding information to calculate risk premiums for Medicare Managed Care Organizations
• HCC payments are linked to the individual health risk profiles for each member in the plan
• HCC codes are captured through accurate physician documentation
Here’s How the System Works• If the average risk score for the overall population is
defined as 1.0, a healthy young man might receive a score of 0.4 based on historical claims data, while a young woman with asthma might be scored at 1.5, and an older person with diabetes might be scored at 2.3.
• A plan having an aggregate score of 1.2 for its enrollees would receive a 20 percent add-on to its average per person payments, while a plan with an aggregate score of 0.8 would experience a 20 percent reduction in payments.
• In practice, individual risk scores, built from data on patient demographics, disability, institutional status, and diagnoses, are used to help determine monthly payments made to plans for each person enrolled in Medicare Advantage, Medicare Part D prescription drug benefits, and many state Medicaid managed care programs.
CDI Case Study
Risk Adjustment 101: Case Study
HCC Calculation
Expect Audits to Validate Coding
• Upcoding can undermine risk adjustment if it distorts the actual health-risk profile of a plan, for example, by suggesting that the people that the plan has enrolled are actually sicker than they really are.
• Expect audit plans to enforce coding “integrity”—that is, consistent use of diagnosis codes to negate any effect of upcoding.
Specificity Opportunities • Depression vs major depression (type)• Asthma vs chronic obstructive asthma/emphysema/chronic
bronchitis• Bronchitis vs chronic bronchitis (acuity/chronicity)• CAD vs angina/unstable angina (severity) • Cardiac dysrhythmia vs atrial fibrillation (specificity) • CVA vs late effect CVA/hemiplegia (current vs late effect)• Diabetes and PVD vs. Diabetic PVD (cause/effect
relationship)• Status of cancer is unclear and treatment is not
documented• Chronic conditions not documented once per year
Common Documentation Challenges
• Problem Lists • Not updated• Title (“Active”, “Chronic”, “Concurrent”)
• Past Medical History (PMH)– Current conditions impacting encounter documented here—and no where else in the
documentation• History of diagnoses
– Coding a past condition as active (CVA, CA, AMI)– Coding history of when condition is still active (COPD, CHF)– “History of CHF” on Lasix vs. “Compensated CHF, stable on Lasix”
• Medication—but no coordinating diagnosis• Ostomy supplies—but not ostomy diagnosis• Labs and radiology ordered—but no indication of why • Physical exam—but no mention of status amputation• Assessment—but not mention of AAA size or status• Inconsistent documentation• Record indicates depression, NOS but diagnosis code written on encounter document
is major depression
Medical Record Requirements• Two patient identifiers on each page: Patient’s name and
birth date • Date of Service (complete and legible) • Face-to-face encounter with acceptable type provider &
setting• Condition(s) must be documented—they cannot be
assumed• Acceptable provider signature, with credential• Documentation, signature and credentials must be legible• No copying/pasting/cloning • Diagnostic test results must be reiterated not copied into
document
Potential Points of Breakdown• Identification
– Do providers review past medical records?– Does EHR integrate across all sources?
• Documentation– If providers are busy, do they record all coexisting conditions?– Do they record their thought processes?
• Coding– Are coders coding all documented conditions?– Are coders aware that 5010 allows up to 12 diagnosis codes?
• Billing – What are the hand-offs between coding and claims submission?– Are all coded diagnoses captured on claim?
• Functional– Do medical records meet stringent HCC requirements?
• Reporting
Risk Adjustment Data Validation AuditsRADV
• National and Targeted Audits• Enrollees are sampled from selected MA
contracts for the purpose of estimating payment error related to risk adjustment
• CMS will select up to 201 enrollees for medical record review from each contract selected for a contract-level audit
• CMS will calculate each contract’s payment error based on the validation results
• Results may be extrapolated against total enrollment
• Payment recovery calculation, if applicable
VBP New Claims-Based Measure• Medicare Spending per
Beneficiary• It is important that the
cost of care be explicitly measured so that, in conjunction with other quality measures included in the Hospital IQR Program, CMS can recognize hospitals that are involved in the provision of high quality care at lower cost
CMS Intent• To measure hospital-specific Medicare spending
per beneficiary, as compared to the median Medicare spending amount across all hospitals nationally
• Will best allow hospitals to recognize where opportunities for improved efficiencies exist
• 3 days prior to hospital admission through 30 days post hospital discharge – Part A & Part B
• Exclude cases involving acute to acute transfers
Medicare Spending Per Beneficiary
• The data for the Medicare spending per beneficiary measure will be posted on Hospital Compare
• CMS has finalized this measure for inclusion in the Hospital VBP Program beginning with the Fiscal Year (FY) 2015 program year.
• CMS to make adjustments for beneficiary age and severity of illness (SOI)– SOI calculated by applying the HCC hierarchical
condition categories which apply to the beneficiary during the 90 days preceding the Medicare spending per beneficiary episode
A Strategic Opportunity• HCCs are assigned using hospital and
physician diagnoses from any of the following sources: – Hospital inpatient• Principal diagnoses• Secondary diagnoses
– Hospital outpatient– Physician, and – Clinically-trained non-physician (e.g.,
psychologist, podiatrist)
If physician documentation is a limiting factor under MS-DRGs, consider the impact
under CMS-HCC
If physician documentation is a limiting factor under MS-DRGs, consider the impact
under CMS-HCC
HCC Purpose • “The ultimate purpose of the CMS-HCC model is
to promote fair payments to MA plans that reward efficiency and encourage high quality care for the chronically ill. “– “CMS is continually conducting research on refining
the CMS-HCC risk adjustment model. A major focus of this research is the incorporation of variables that increase the predictive accuracy of the CMS-HCC model for high-cost beneficiaries for whom the model doesn’t fully predict expenditures.”
• Does anyone not think this will be used for ACO bundled payment?
CMS Finalizes• Program Changes for Medicare
Advantage and Prescription Drug Benefit Programs forContract Year 2015 (CMS-4159-F)
• Improving payment accuracy: Report and return identified Medicare overpayments but cannot submit diagnosis codes for additional payment
Thinking Outside the Box;Protect your Ambulatory Documentation • Traditional CDI programs focus on concurrent
inpatient review of documentation • Ambulatory records are just as vulnerable to
documentation scrutiny – Records that lack specific diagnoses will be denied
for payment – Physicians need feedback on what documentation
must be included for hospitals to get paid
CDI Mitigating Risk: 3rd Party Audits
• Perform CDI review on all cases that are requested for review– Appropriate documentation to support coding?– Assist with Medical Necessity review
• Clinical expertise is critical when defending against auditors (RAC, OIG, 3rd party coding audits)
• CDI part of your multidiscplinary team approach to defend your records
CDI at Work in the Ambulatory SettingHospital denied reoccurring chemotherapy charge because only one cancer was
documented
CDI at Work in the Ambulatory SettingExample: Hospital denied reoccurring chemotherapy charge because only
one cancer was documented
Original denial: $170,000
CDI at Work in the Ambulatory SettingExample: Hospital denied payment for device based on lack of
documentation by surgeon
Dr. XXX ,We have a denial from Medicare on a patient that
received a VNS (attached). Medicare needs to have documentation of either A) a failed surgery prior to the VNS or B) documentation that the patient is not a good surgical candidate and therefore needs the VNS.
Based on my review, this patient is quite complex and would like your opinion if he falls into the “B” category. Would you please review and if you agree, amend your note to include that phrase? If this patient does not meet A or B, please let me know and we will accept the denial of this surgery.
CDI at Work in the Ambulatory SettingExample: Hospital denied payment for device based on lack of
documentation by surgeon
Dr. XXX ,We have a denial from Medicare on a patient that
received a VNS (attached). Medicare needs to have documentation of either A) a failed surgery prior to the VNS or B) documentation that the patient is not a good surgical candidate and therefore needs the VNS.
Based on my review, this patient is quite complex and would like your opinion if he falls into the “B” category. Would you please review and if you agree, amend your note to include that phrase? If this patient does not meet A or B, please let me know and we will accept the denial of this surgery.Original denial: $150,000
Formalize Your Denial ProcessBest Practice: 1.Ensure you have the right people at the table2.Track results3.Meet monthly to review progress
SOLUTIONS AND NEXT STEPSAssessmentEducation HCC CDIImplementation
A Strategic Opportunity• HCCs are assigned using hospital and
physician diagnoses from any of the following sources: – Hospital inpatient• Principal diagnoses• Secondary diagnoses
– Hospital outpatient– Physician, and – Clinically-trained non-physician (e.g.,
psychologist, podiatrist)
If physician documentation is a limiting factor under MS-DRGs, consider the impact
under CMS-HCC
If physician documentation is a limiting factor under MS-DRGs, consider the impact
under CMS-HCC
HCC CDI Program Benefits
Moving Forward• Education, analytics and workflow solution addressing
the challenges of outpatient CDI and HCC coding requirements
• Extend the current CDI workflow to support a centralized model of concurrent review of suspect HCC
• Capture pre-billing by leveraging the Systems CDS department and your investment in best practices and tools
• Improve revenue capture for Medicare Advantage Plan, Value-Based-Purchasing, and ACO initiatives
Summary• “The ultimate purpose of the CMS-HCC model is
to promote fair payments to MA plans that reward efficiency and encourage high quality care for the chronically ill. “– “CMS is continually conducting research on refining
the CMS-HCC risk adjustment model. A major focus of this research is the incorporation of variables that increase the predictive accuracy of the CMS-HCC model for high-cost beneficiaries for whom the model doesn’t fully predict expenditures.”
• Does anyone not think this will be used for ACO bundled payment?
