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The Trap of Reporting QualitySession COM 3: March 5, 2018
Marion Salwin CPC, CCS, COC, CPC-I
Trinity Health
Zahid Butt MD, FACG
Medisolv Inc.
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Marion Salwin
Zahid Butt
Have no real or apparent conflicts of interest to report.
Conflict of Interest
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This presentation was prepared as a service to the public and is not intended to grant rights or impose obligations. This presentation may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations, and other interpretive materials for a full and accurate statement of their contents.
Disclaimer
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Learning Objectives
• Define and defend areas within your own care venues that are at risk for quality reporting compliance issues
• Identify key areas of clinical documentation integrity to facilitate excellence in coding, billing and quality reporting
• Develop a team approach to managing risks
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Value is the New Economy
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Sources of Value-Defining Data
Cla
ims
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Value-based initiatives target improving quality of care and containing cost by:
• Connecting reimbursement to measured quality outcomes and efficiency
• Promoting coordination of care among providers
• Emphasizing primary care and home-based/pre-acute care
• Reducing hospital admission and readmissions
• Expanding the use of Health Information Technology (HIT) and Big Data
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The Clinical Divide In Documentation
PROVIDER VIEW PAYER VIEW
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The Impact of the Clinical Divide
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Risk Adjustment Across the Continuum
• 42% overlap between HCCs and CCs
• 16% overlap between HCCs and MCCs
• 25% overlap between CMS-Condition Categories and CC/MCCs
• 80% of HCCs are CMS-Condition Categories
• 58% of CMS-Condition Categories are HCCs
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Quality Based Financial Incentives for Physicians
• Pay for Performance (P4P) rewards hospitals for quality care given by physicians
• Aligning incentives of hospitals with physicians without violating fraud and abuse laws - Gainsharing
• Reward physicians financially for achieving quality incentives
– Peer Review
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Potential Provider Fraud Related to Health Care Quality Initiatives
• Billing for services not provided
• Upcoding-billing for a higher level of service than was provided, or billing for services that did not meet the P4P or P4R incentive payment conditions
• Billing for higher DRG for a hospital acquired condition not present upon admission (based on documentation)
• Failure to provide appropriate care
• Unnecessary and incorrectly performed procedures
• Billing for a serious adverse event when not permitted
• Poor quality, intentionally to save money
• Evidence of pervasive billing and coding compliance issues
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What’s Next ?
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Leadership Support & Discussions• What processes are in place to promote the reporting of quality concerns
and medical errors?
• Are there enough resources available to support patient safety and clinical quality
– Are resources continuously evaluated to meet the changing demands of clinical quality and patient care?
• Assurance that the hospitals competency assessment and training, credentialing, and peer review processes adequately recognize the necessary focus on clinical quality and patient safety issues
• Understand how adverse patient events and other medical errors are identified, analyzed, reported and incorporated into the organization’s performance improvement activities
• How are quality deficiencies addressed without increasing the hospitals liability?
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Improve Quality Compliance & Oversight• Evaluate quality to the same level of finance and regulatory
compliance
• Understand relevant patient safety and quality measures and issues
• Establish a system of performance goals and monitoring elements to ensure compliance
• Involve individuals who are knowledgeable in quality measures and compliance activities
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Education & Provider “Buy In”
• Partner with early adopters, champions and leaders “in the field”
• Be flexible
• Share data
• Providers are partners
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From Data To Performance Measures!!
*
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*Clinical Document Improvement
**Electronic Clinical Quality
Measures
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Coding Guidelines & Conventions Provider Documentation Required
Principal Diagnosis Assignment
Secondary Diagnoses Listing
Present On Admission Designation
Surgical & Other Procedure Indications
Surgical & Other Procedure Complications
Other Clinician Documentation
Attributes may add to Coding specificitye.g. Nursing Notes for Pressure Ulcer Staging
It’s All About Documentation
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Claims Measures; Coding Impact
Measure Results / Scoring
Denominator
Numerator
Exclusions / Exceptions
Risk Adjustment Algorithms
Co-Morbidity aka “Secondary” Diagnosis
Core Clinical Data Elements in Hybrid Measures
Documentation & Coding
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Present On Admission (POA)
Patient Safety Measures
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Patient Safety Indicators (PSI) Pressure Ulcers (PSI 03)
Improper Present On Admission (POA) Flag due to missing documentation in H&P
Death in Low Mortality DRG (PSI 02)
Improper Selection of Principal Diagnosis
Incorrect Assignment to “Low Mortality DRG”
Death in Surgical Inpatients with Serious Treatable Complications (PSI 04)
Incomplete List of Secondary Diagnosis
Incorrect Admit Type. Only Elective Admissions (Admit Type = 3) are considered in Denominators
Patient Safety Measures
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Perioperative Hemorrhage or Hematoma (PSI 9)
Ecchymosis vs. Hematoma
Expected vs. Excessive Bleeding
Second Procedure to “Control” Bleeding
Coagulation Disorder documentation
Unrecognized Puncture or Laceration (PSI 15)
Integral to Procedure vs. Unintended
Bleeding alone should not be coded for this
Patient Safety Indicators (PSI)
Patient Safety Measures
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Documentation in eCQM’s
Annual Plan
eCQM
Specifications
Annual Update
EHR Application
Functionality
Clinical Workflows
EHR Data Sources
Data Validation
&
Measure Improvement
Regulatory Requirements
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Clinical Documentation Improvement Avoid abbreviations and symbols
Optimize structured data/standardized data workflows
Finalize working diagnosis (rule out / possible)
Accurate principal diagnosis (reason for admission)
Record ALL secondary diagnosis / POA
Accurate surgical & other procedure records
Understand coding guidelines / regulations
Collaborate with coders / CDI specialists
“If its not documented, it didn’t happen.”
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CMS Inpatient Quality Reporting Audits CDAC Annual Chart-Abstracted Data Audit
Random sample of 400 Hospitals in December, 2017
Targeted sample of 200 Hospitals in April, 2018
Cases include Hospital Acquired Infections
Need to meet minimum data validation criteria
CDAC for Electronic Clinical Quality Measures (eCQMs)
Random sample of 200 Hospitals in April, 2018
Need to meet minimum medical record submission criteria
Hospitals selected for the chart-abstracted audit will be excluded from the eCQM audit
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Marion Salwin
• 734-343-2534
Zahid Butt
• 443-539-0505 Ext. 223
• @zbytes
Reminder: Please Remember To Fill Out Evaluation Forms
It Helps Us to Improve The Quality of Our Presentations
Questions
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Sources• Centers for Medicare & Medicaid Services (CMS) Hierarchal
Condition Categories
• Adriane Martin, DO, FACOS, CCDS, “Hierarchal Condition Categories and Clinical Documentation: The Core of Risk Adjustment”
