Teaching physicians: What’s in it for me (WIIFM)

Margi Brown, RHIA, CCS, CCS-P, CPC

Objectives

This “what’s in it for me” session will cover how to get the busiest physician/provider’s attention and keep it with the goal of accurate documentation in mind.

Topics of discussion

Establishing the initial contact.

Determining the focus of the presentation(s) and other efforts.

Compiling numbers that impact the physician.

Providing take-away tools.

Sparking interest in their office setting.

Avoiding potholes on the way .

Ensuring ongoing marketing and feedback .

Taking the next steps: Once they are hooked, then what?

Determine your bottom line

Hospitals and each physician need the most accurate and specific documentation that translates into correct and compliant coding to reflect the true complexity of care and severity of illness of their patients.

Initial steps

Before initiating any contact with providers …

Common goals

Set responsibility

Common goals

Set game plan: – Involvement, staging, calendar

Information likely disseminated through insurance company’s website

HealthGrades for hospitals

And soon MDs as well,provided that Consumer Checkbook wins its appeals

Physician public profiling

Pay for performance

Definition: Pay for performance (P4P) is a catchphrase for a management tool that establishes incentives for clinicians and institutions (e.g., hospitals) to deliver care that third parties deem is necessary and appropriate to achieve the highest-quality standards and best outcomes.

Current Metrics:– Process-oriented activities

Core Measures, Physician Quality Reporting Initiative (PQRI)– Infrastructure improvements

Principally information technology—CPOE – Patient outcomes

Risk-adjusted mortality

P4P goal: Increase value

Defined as outcomes (quality) ÷ Cost– Cost is easy to identify– Outcomes (quality) is not.

The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.

Discernment – What do we measure?– Process functions? (e.g., door-to-wire time)– Death? –Was it expected or unexpected?– Complication rates? –What is preventable and what is not?– Functional outcome? – Patient satisfaction?

Dissemination– How to we communicate our results to our constituency?

Goals for both

Physicians:– Encourage physicians to deliver their ethical obligation to practice evidence-

based medicine while better allocating resources– More proximal to the medical decision-making

Power of the pen Power of the knife

– Leverage with hospitals is professional relationships or to move their practice to a competitor

Hospitals:– Better develop systems and support

Less proximal but still critical– Leverage with physicians is professional relationships or medical staff

credentialing. Relationships – “Win-Win” between physician and facility Credentialing–like firing a poor-performing employee

Physician reimbursement“Tier and Steer” networks

Three proposed office visit tiers based on cost and “quality of care” by physician:

– $15/10% co-payment for tier 1 MD

– $30/20% co-payment for tier 2 MD

– $45/30% co-payment for tier 3 MD

Physician profiling example—Blue Cross of Texas

No changes—still measurable …

Where do you fall in the “bell” curve ?

or

OBS vs. inpatient—matching? Observation

Initial OBS day (3/3): 99218 –99220

Same DOS for admit/disch (3/3): 99234-99236

Disch: 99217

“Extra” days (2/3): 99211-99215 (per CMS)

Inpatient Admit, H&P (3/3): 99221-99223

Same DOS for admit/disch (3/3): 99234-99236

Subsequent day (2/3): 99231-99233

Disch: 99238 - < 30 minutes & 99239 - > 30 minutes

Complexity of medical decision-making Refers to the complexity of establishing a

diagnosis and/or selecting a management option as measured by the following:

– Number of possible diagnoses and/or management options

– Amount and/or complexity of data– Risk to the patient

1. Number of Diagnoses or Treatment Options

A DCB

Problem(s) Status Number Points Results

Self limited/minor

Established problem to examiner … stable/improved

Established problem to examiner … WORSENING

New problem to examiner w/additional workup planned

New problem to examiner w/no additional workup planned

1

max=1

max=2

1

2

3

4

TOTAL:

Complexity of medical decision-makingDetermined by (1) Number of diagnoses or treatment options, (2) Amount and/or complexity of data reviewed, and (3) Risks of complications and/or morbidity or mortality

Risk of significant complications, morbidity and/or mortality For E/M: The risk to the patient is based upon

the highest level of risk associated with the:– Presenting problem(s) – Diagnostic procedure(s)– Possible management options

Explain the data source

For both hospitals and physicians: – Documentation is the bottom line for both, leading

to the translation process of narrative diagnoses and procedures to numbers –codes

– Comparison of ICD-9-CM and CPT/HCPCS systems

– “Severity adjustment” – Mortality and morbidity rates

Hospital—IPPS—Inpatient Prospective Payment System methodology

One set payment to the hospital is determined by assignment:

Of codes for all (documented) diagnoses and procedures

To one Major Diagnostic Category (MDC)

Then further to one MS-DRG

All statistics are based on billed case-mix index (CMI)

Daily notes

Who?

What?

Where?

When?

How?

Why?

Why is the patienthere today?

Each note must:

Support what is coded and billed

Stand alone

Be legible

Show medical necessity

Medical necessity and the correct level "Medical necessity of a service is the overarching criterion for

payment in addition to the individual requirements of a CPT code.

It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted.

The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported.“

(CMS Claims Processing Manual (Publication 100-04), Chapter 12, Section 30.6.1 - Selection of Level of Evaluation and Management Service).

Reimbursement factor—RW

RW (Relative Weight)—Weighted number assignment

Hospital: This number is assigned to each MS-DRG. The assigned weight is intended to reflect relative resource consumption associated with each DRG.

Physician: This number is assigned to each CPT/HCPCS code.

CMI and the provider

Low CMI = low “severity” low “quality”?

High CMI = high expected cost & LOS?– My patient’s are sicker.

Measurement of high cost with low CMI = loss for patient, insurance company, hospital, and physician? (contracts?)

Credentialing, pay for performance – how does the physician rate?

Complete picture of quality, core measures, resource consumption, LOS, cost, compliance, audit risk, and much more.

Analyze the stats

Dr. 1 1.03 Dr. 2 0.96 Dr. 3 1.11 Dr. 4 1.07 Dr. 5 1.03 Dr. 6 1.05 Dr. 7 1.10 Dr. 8 1.17 Dr. 9 1.05 Dr. 10 1.04 Dr. 11 1.03 Dr. 12 0.95 Range = 0.95 – 1.17

If Medicare Reimbursement for case mix of 1.0 = $4500 per patient– Low = 4275– High = 5265

– most likely to risk RAC?– best mortality adjusted data?– discharge patients with more

symptom diagnosis? (chest pain, syncope, AMS…)

Analyze the stats

Doctor 1 1.28

Doctor 2 0.81

Doctor 3 1.15

Doctor 4 1.42

Doctor 5 1.09

Pulmonary /Critical Care

Range: 0.81 – 1.42

If Medicare reimbursement for case mix of 1.0 = $4500 per patient

– Low = 3645– High = 6390

– Have illegible handwriting?– Show the most resistance to coding

queries?– Will have the highest mortality (risk

adjusted)?– Are most likely to have his/her data

published in the newspaper

PD—Principal diagnosis

Coding guideline for inpatient hospital cases

Principal diagnosis– "that condition established after study to be

chiefly responsible for occasioning the admission of the patient to the hospital for care.“

Acute

Could notbe treated as

outpatient

Meets admitcriteria

Acutely treated

AggressivelyManaged

Principal Diagnosis

The principal and the why’s

Secondary diagnoses and other Comorbidity:

– A pre-existing condition that affects the treatment received or the length of stay

Complication: – A condition that arises during the hospital stay that affects the

treatment received or the length of stay

MCC or CC

Data integrity

Medical necessity

Where do you draw the line?

Discharge status

When does it count?

Example of vagueness

Provide real-life samples

Now ask: What was their billing for the physician?

– Critical care? – Level: 9923_: 1,2, or 3?– Medical necessity– Link back to their bell curve, their stats, and

compare to the hospital stats

POA defined

POA—Present on Admission purpose– To differentiate between conditions present on

admission and conditions that developed during an inpatient admission.

– The focus is to assess the timing of when the condition presented. Pre-existing or hospital-acquired?

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HAC –Yes or no, and why?

Indicator DefinitionHow a HAC will be treated with this indicator

YYes; POA Will assign to higher

weighted DRG

NNo; Not POA Will NOT assign to higher

weighted DRG

UUnknown: insufficient documentation

Will NOT assign to higher weighted DRG

W

Clinically Undetermined: Unable to determine based on clinical picture.

Will assign to higher weighted DRG

Liability implications

Were prevention guidelines followed?

Public reporting of infections, hospital-acquired conditions (HACs).

MD-specific data on HACs.

Increase in lawsuits against hospitals/MDs.

Some HACs or infections are expected.

How can hospitals/MDs defend against HACs?

Provider defined for POA

“Medical record documentation from any provider (a physician or any qualified healthcare practitioner who is legally accountable for establishing the patient’s diagnosis) involved in the patient’s care and treatment may be used to support the determination of whether a condition was present on admission or not; and the importance of consistent, complete documentation in the medical record cannot be overemphasized”

MLN Matters number: MM5499 Related Change Request Number: 5499, 091107 update and Transmittal #289 071707 update

Joint effort

“Finally, you should keep in mind that achieving complete and accurate documentation, code assignment, and reporting of diagnoses and procedures requires a joint effort between the healthcare provider and the coder.”

MLN Matters number: MM5499 Related Change Request Number: 5499, 091107 update and Transmittal #289

071707 update

Top Ten 2007 RW 2008/2009 MS-DRG(s) 291 w MCC: 1.2585 / 1.4465 292 w CC: 1.0134 / 1.0069

127 Heart Failure

1.0490

293 w/o: 0.8765 / 0.7220 193 w MCC: 1.2505 / 1.4327 194 w CC: 1.0235 / 1.0056

89 Simple Pneumonia with CC

1.0376

195 w/o: 0.8398 / 0.7316 469 w MCC: 2.6664 / 3.2901

544 Major Join Replacement or Attachment

1.9878 470 w/o MCC: 1.9871 / 2.0077 190 w MCC: 1.1138 / 1.3030 191 w CC: 0.9404 / 0.9757

88 Chronic Obstructive Pulmonary Disease

0.8878

192 w/o: 0.8145 / 0.7254 871 w MCC: 1.7484 / 1.8222

576 Septicemia w/o Vent > 96 Hours

1.5996 872 w/o MCC: 1.3783 / 1.1209 391 w MCC: 0.9565 / 1.0856

182 Esophagitis, Gastroenteritis, etc with CC

0.7853 392 w/o MCC: 0.7121 / 0.6703

64 w MCC: 1.5470 / 1.8450 65 w CC: 1.1901 / 1.1760

14 Stroke

1.2118

66 w/o: 1.0303 / 0.8439 377 w MCC: 1.3367 / 1.6073 378 w CC: 1.0195 / 1.0043

174 Gastrointestinal Hemorrhage with CC

1.0296

379 w/o: 0.8476 / 0.7565 682 w MCC: 1.4664 / 1.6403 683 w CC: 1.1942 / 1.1304

316 Renal Failure

1.2602

684 w/o: 0.9835 / 0.7305 689 w MCC: 1.0587 / 1.2301

320 Urinary Tract Infection

0.8769 690 w/o MCC: 0.8000 / 0.7581

National top 10 list

What do you mean?

Low H/H Insufficiency/distress Infiltrate Hypotension

Symptom, sign, or AMS, weakness, chest pain, … Contradiction (attending vs.

consultant) or terms

Lab/radiology/path

finding Acuity

Anemia … due to- Failure Pneumonia or CHF Shock. ? Type, ? other

Due to, Link, Diagnosis/disease

Clear and concise

Clinical significance

Acute, chronic, acute on chronic

Provide examples of inference “Clinically” or “reasonably” vs. actual documentation Meaning? Interpretations differ? CMS to set the policy:

– Determinations are “inconsistent”– Error rate is “compromised”

“lack of understanding documentation requirements” Disservice by “under-documenting”

– Continuity of pt care, severity, LOS, resources– Patient – prevent from obtaining necessary services?

Increased and inaccurate out of pocket costs?

Call it what it is

Obesity– Morbid obesity

Delirium

Sepsis vs. urosepsis

(VAP)—“Ventilator associated pneumonia” specifically documented by the physician

Hypoxia

“Acute” exacerbation …

Heart failure weighted

Did the decubitus exist POA?

Where was patient admitted from?

Is there a skin exam in the ER or by the admitting physician?

Check the H&P.

Skin breakdown, redness, when was this initially noted and by whom?

Is the diagnosis of “ulcer”, the type, the stage, and POA clearly documented?

Physician query is required.

Superficial well-defined decubitus ulcer

Before skin breakdown into an ulcer – redness

Wound progression “It is possible for a wound to

"go from a stage I wound to a stage III or IV" without the intermittent stage[s] being observed.

All wound stages were present just not obvious, hence the need to treat all wounds as serious with the potential of rapidly worsening.”

www.expertlaw.com/library/malpractice/decubitus_ulcers.html

Stage 4 decubitus ulcer

Values Commonly Used to Grade the Severity of Protein-Energy Malnutrition

Measurement Normal Mild Malnutrition Moderate Malnutrition

Severe Malnutrition

Normal weight (%) 90–110 85–90 75–85 < 75

Body mass index 19–24* 18–18.9 16–17.9 < 16

Serum albumin (g/dL) 3.5–5.0 3.1–3.4 2.4–3.0 < 2.4

Serum transferrin (mg/dL)

220–400 201–219 150–200 < 150

Total lymphocyte count (per mm3)

2000–3500 1501–1999 800–1500 < 800

Delayed hypersensitivity index†

2 2 1 0

*In the elderly, BMI < 21 may increase mortality risk.

†Delayed hypersensitivity index quantitates the amount of induration elicited by skin testing using a common antigen, such as those derived from Candida sp or Trichophyton sp. Induration grade 0 = < 0.5 cm, 1 = 0.5–0.9 cm, 2 = ≥ 1.0 cm.

http://www.merck.com/mmpe/sec01/ch002/http://www.merck.com/mmpe/sec01/ch002/ch002b.htmlch002b.html

Symptoms—Diagnoses?

Different diagnosis potential, different codes, and different MS-DRGs, with different reimbursement:

– Seizure–100-101– Syncope–312

Near syncope– Orthostasis

Orthostatic hypotension–312 – Vertigo, dizziness – (dysequilibrium)–149 – Weakness–947-948– Altered mental status–947–948– Decreased level of consciousness– Alteration of consciousness—081 – Dementia—884

Underlying cause due to more specific diagnosis?

AMS

Chest Pain

Mass

Weakness

Hypoxia

Insufficiency

Distress

SOB

Clarify Underlying Cause

Encephalopathy choices—Many types, many codes, many MS-DRGs, and RW difference

Alcoholic 291.2 MS-DRG 894-896 (FY08: 0.3571–1.0419, FY9: 0.3878-1.327)

Chronic cerebral ischemic 437.1 – MS-DRG 069 (FY08: 0.7339, FY09: 0.7157)

Due to dialysis 294.8-MSDRG 884 (FY08: 0.8431, FY09: 0.8992)

Hepatic 572.2 – MS-DRG 441-443 (FY08: 1.3973 – 0.9079, FY09: 106639-0.6982)

Hypertensive 437.2 – MS-DRG 077-079 (FY08: 1.4611-0.9839, FY09: 106233-0.7398)

Hypoglycemic 251.2 or – Wernicke’s 265.1 MS-DRG 640-641 (FY08: 0.9793-0.7248, FY09: 1.1138-0.6820)

Metabolic 348.31 or Unspecified 348.30 – MS-DRG 070-072 (FY08: 1.6212-0.9586, FY09: 1.8246-0.7650)

Post-traumatic 310.2 – MS-DRG 101-102 (FY08: 0.8258-0.8710, FY09: 0.7617-0.9584)

Toxic and Toxic-metabolic 349.82 – MS-DRG 091-093 (FY08: 1.3242 – 0.7710, FY09: 1.5747-0.6777)

Stroke MS-DRGs and weights

Sepsis clinical definitions

1991 ACCP/SCCM consensus conference definitions Sepsis = Infection + SIRS* Severe Sepsis = Infection + SIRS + Organ Dysfunction Septic Shock = Infection + SIRS + Organ Dysfunction + Hypotension

*Note: SIRS= Systemic Inflammatory Response Syndrome

Diagnosis Definition

Bacteremia Nonspecific laboratory finding of bacteria in the blood with no signs of illness.

Septicemia

Systemic disease associated with the presence and persistence of pathogenic microorganisms in the blood. Clinical manifestations may be a positive blood culture and fever.

Sepsis

Infection-induced syndrome in the presence of two or more manifestations of SIRS without organ dysfunction. Septicemia that has advanced to involve two or more manifestations of SIRS.

Severe sepsis Two or more manifestations of SIRS with organ dysfunction.

Septic shockSevere sepsis in which the cardiovascular system begins to fail, blood pressure drops, and vital organs are deprived of adequate blood supply .

Chronic kidney disease codes, GFR, and weights Stage I Kidney damage

with normal or high GFR > 90 585.1

Stage II Kidney damage with mild decrease in GRF 60-89 585.2

Stage III Moderate decrease in GFR 30-59

585.3

Stages I-III non CCs

IV Severe decrease in GFR 15-29 585.4

V Kidney failure .15 (or dialysis) 585.5

End Stage Renal Disease 585.6

HTN chronic kidney disease code each stage

HTN/HEART kidney disease

Stages IV –V CCs, Stage VI MCC

Simple pneumonia MS-DRGs

MS-DRG 195 Simple Pneumonia without MCC/cc– RW .8398 - FY08, 0.7316-FY09– GMLOS = 3.5– Multiple 5000 x RW .8398 = $4199.00 - $3658

MS-DRG = DRG 194 Simple Pneumonia with cc– RW = 1.0235 - FY08, 1.0056-FY09– GMLOS = 4.4 – Multiple 5000 x RW 1.0235 = $5117.50 - $5028

MS-DRG = DRG 193 Simple Pneumonia with MCC– RW = 1.2505 - FY08, 1.4327-FY09– GMLOS = 5.4 – Multiple 5000 x RW 1.2505 = $6252.50 – $7163.50

Hospital Base Rate = $5000

Respiratory failure

518.81 Acute Respiratory Failure = MCC

518.84 Acute & Chronic Resp Failure = MCC

518.82 Other pulmonary insufficiency = CC

518.83 Chronic respiratory failure = CC

Both are defined as an inadequate gas exchange by the respiratory system where the lungs cannot take in sufficient O2 or expel sufficient carbon dioxide to meet the needs of the body.

Average national mortality rates

Simple PNA--(DRG 193-195)– 2.5%

Complex PNA--(DRG 177-179)– 20%

Sepsis (DRG 871-872)– 20%

UTI (DRG 689-690)– 1.5%

Physician

Hospital Leadership

Clinicians

Coders

CDCI

A Clinical Documentation Coding Integrity (CDCI) program is a concurrent, retrospective, and proactive multi-disciplinary approach, with physician involvement with the goal to improve the completeness and specificity of clinical documentation to allow appropriate capture of patient severity.

Audience Questions???