HAC, RAC, Decreasing Readmissions: An HCE Update

1. HAC, RAC, Decreasing Readmissions: An HCE Update Roland A. Grieb, MD, MHSA Medical Director October 29, 2009

3. Objectives Describe how the Centers for Medicare and Medicaid Services� (CMS) Value-Based Purchasing (VBP) program relates Hospital Acquired Conditions (HACs)/ Present-on-Admission (POA) as outcomes of care Provide updates to the Recovery Audit Contractors (RAC) program Discuss how specificity in clinical documentation influences reimbursement, patient safety, and outcomes of care that are publicly reported. Review the current status of the Care Transitions project in Indiana

4. What Is Medicare Going to Do to Survive? Three ways to make Medicare last longer and bring the costs down Spread the costs of Medicare among Medicare beneficiaries Reduce provider prices Optimize utilization and benefits, and focus on quality of care

5. The Changing Face of Medicare Since Its Beginning

6. Medicare �R� Tools Reimbursement Regulations Resources Reporting

7. VBP Program Goals Improve clinical quality Reduce adverse events and improve patient safety Encourage patient-centered care Avoid unnecessary costs in health care delivery Stimulate investments in effective structural components or systems Make performance results transparent and comprehensible

8. What Does VBP Mean to CMS? Transforms Medicare from a passive to an active payer of health care Provides tools and initiatives for promoting higher quality of care, while avoiding unnecessary costs

9. Centers for Medicare & Medicaid Services (CMS) Roadmaps for Value Driven Healthcare Value-Based Purchasing (VBP) Quality Measurement Resource Use Measurement Plan Source: http://www.cms.hhs.gov/QualityInitiativesGenInfo/ 10/22/2009 9

10. �Report to Congress: Plan to Implement a Medicare Hospital Value-Based Purchasing Program�* Options for implementing a VBP program in fiscal year (FY) 2009 presented to Congress in November 2007 * http://www.cms.hhs.gov/AcuteInpatientPPS/downloads/ HospitalVBPPlanRTCFINALSUBMITTED2007.pdf

11. VBP and Hospitals Builds on existing framework of the pay-for-reporting program Rewards hospitals that maintain or improve and attain quality performance Incentive payment amount would be a percentage of the diagnosis-related group (DRG) payment

12. VBP Update September 9, 2009: Chairman of the Senate Finance Committee, Max Baucus (D-MT), released a document titled �Framework for Comprehensive Health Reform� Hospital Value-Based Purchasing Physician Value-Based Purchasing Reducing Hospital Acquired Infections Reducing Avoidable Hospital Readmissions http://finance.senate.gov/press/Bpress/2009press/prb090909.pdf

13. Hospital Acquired Conditions (HACs) and Present on Admission (POA) Deficit Reduction Act (DRA) Section 5001(c) is the statutory requirement for HACs conditions and POA Translation No increased payment for complicating conditions that are not present at the time of hospital admission If the HAC is the only complication or comorbidity, then it will not lead to the higher paying DRG

14. Statutory Authority DRA Section 5001 (c) Currently applies only to acute Medicare inpatient prospective payment system (IPPS) hospitals�those reimbursed under Diagnosis Related Groups (DRGs) Currently excludes Critical Access Hospitals (CAH), psychiatric and rehabilitation hospitals, and distinct part units Web source for HACs http://www.cms.hhs.gov/HospitalAcqCond/07_EducationalResources.asp.

15. HACs CMS must select conditions that meet the following criteria High cost, high volume, or both Assigned to a higher paying DRG when present as a secondary diagnosis �Reasonably preventable� through the application of evidence-based guidelines

16. CMS-Selected HACs Foreign objects retained after surgery Air embolism Blood incompatibilities Catheter-associated urinary tract infections (UTIs) Vascular catheter-associated infections Pressure ulcers (Stages III & IV)

17. CMS-Selected HACs (cont.) 7. Falls and other hospital-acquired injuries Fracture, dislocation Intracranial injury Crushing injury Burn Electrical shock

18. CMS-Selected HACs (cont.) Manifestations of poor glycemic control Hypoglycemic coma Diabetic ketoacidosis Nonketotic hyperosmolar coma Secondary diabetes with ketoacidosis Secondary diabetes with hyperosmolarity Deep vein thrombosis (DVT)/pulmonary embolism (PE) Total knee replacement Hip replacement

19. CMS-Selected HACs (cont.) Surgical Site Infections Mediastinitis after coronary artery bypass graft (CABG) Certain orthopedic procedures Spine Neck Shoulder Elbow Bariatric surgery for obesity Laprascopic gastric bypass Gastroenterostomy Laparoscopic gastric restrictive surgery

21. POA�General Requirements Defined as �present at the time the order for inpatient admission occurs� Multiple clinical scenarios qualify as POA Diagnosed prior to admission (e.g., history of diabetes) Confirmed during the admission but documented at the time of admission as �suspected,� �possible,� �Rule/Out,� or as a differential diagnosis

22. POA General Requirements (cont.) Multiple clinical scenarios qualify as POA Diagnosed after admission, but documented as an underlying cause of a symptom present at the time of admission Present during an outpatient encounter prior to order for admission (e.g., Emergency Department, observation status, or outpatient surgery)

23. HAC will continue to evolve and expand CMS is considering ways to make HAC more precise, including risk-adjusting for a condition's prevalence, and assessing rates of a condition's occurrence over time CMS is also looking into expanding the policy of �Health Care Acquired Conditions� to other payment settings, including outpatient hospitals, ambulatory surgery centers, physicians' offices, home health agencies, and skilled nursing facilities The Future

24. Practical Approaches to Address CMS Requirements Transition in format from �pay-for-reporting� to �pay-for-performance� Introduction of drivers for evidenced-based quality care and measurement Requires true coordination between clinicians, coders, and billing office Not only a documentation issue or solely a coding and/or revenue cycle issue

25. Practical Steps Clinical teams should review literature of evidence to establish local evidence-based protocols and steps to avoid HACs and �Never Events� Not the care paths of yesteryear Establish interpretation and documentation expectations for POAs Templates to support documentation

26. Practical Steps (cont.) Expectation of compliance with protocols� measure and monitor Resources requirements Establish strong and reliable data collection systems that are real time Consistent, reliable feedback loop from coding and patient financial services back to clinical services to drive refinement of process

27. National Coverage Determinations (NCD) On January 15, 2009, CMS issued three NCDs to establish uniform national policies that will prevent Medicare from paying for certain serious, preventable errors in medical care Wrong surgical or other invasive procedures performed on a patient Surgical or other invasive procedures performed on the wrong body part Surgical or other invasive procedures performed on the wrong patient

28. Recovery Audit Contractor (RAC) Program Congress mandated the RAC program Section 306 of the Medicare Modernization Act (MMA) directed the three year RAC demonstration program Goal of the recovery audit program is to identify improper payments made on claims of health care services provided to Medicare beneficiaries.� www.cms.hhs.gov/RAC

29. What is a RAC? The RACs detect and correct past improper payments so that the Centers for Medicare & Medicaid Services (CMS) can implement actions that will prevent future improper payments Providers can avoid submitting claims that do not comply with Medicare rules CMS can lower its error rate Taxpayers and future Medicare beneficiaries are protected

30. RAC Examples: Hospital Improper Payments Wrong Principal Diagnosis (PDX) Incorrect coding, PDX on claim not matching PDX in the medical record Most common DRGs were 475 (Respiratory System Diagnosis) and 468 (Extensive operating room (OR) Procedure Unrelated to Principal Diagnosis) Wrong Diagnosis Code Incorrect coding of ICD-9 03.89 (Septicemia) when medical record supports a diagnosis of Urosepsis/Urinary Tract Infection (UTI) Excisional debridement compared to non-excisional debridement

31. Plans for RAC Expansion The RAC demonstration program has proven to be successful The program has returned significant dollars to the Medicare Trust Fund CMS views the RAC demonstration as a value-added adjunct to its other present programs

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33. Improvements to RAC Permanent Program Look-back period reduced Four years to three years Will not be allowed to look at claims paid prior to October 1, 2007 (start of new Medicare Severity DRG reporting) Mandatory medical record limits set by CMS Certified coders are required

34. Improvements to RAC Permanent Program (cont.) RAC Medical Director discussion Required and frequent reporting of problem areas identified Must pay back contingency fee if appeals are lost at any level Uniform external RAC validation process is mandatory

35. Lessons Learned Use data gleaned from your knowledge of coding, DRGs, the Comprehensive Error Rate Testing (CERT) program data, the Office of Inspector General (OIG) Work Plan, and RAC �mentality� Internal Data Mining High Risk DRGs High Volume DRGs/High Volume Outpatient Services

36. Next Steps RAC goes arm-in-arm with proposed Medicare Severity (MS)-DRG methodology, ICD-10 implementation, and CMS HAC/POA criteria Comprehensive physician documentation and accurate clinical coding are �Must Haves�

37. CMS Approved Audit Issues Posted for Region B Recovery Audit Contractor Blood transfusions IV-hydration Bronchoscopy Services Neulasta Once in a lifetime procedures Untimed codes

38. Resources CMS RAC Web site: www.cms.hhs.gov/RAC Frequently Asked Questions Updates RAC Statement of Work Fact Sheet Appeals Information Change Requests related to RAC CMS RAC E-mail: RAC@cms.hhs.gov

39. Region B RAC Contractor REGION B CGI Technologies and Solutions, Inc. Subcontractor: PRG Schultz Web site: http:// racb.cgi.com E-mail: racb@cgi.com Telephone: 1-877-316-7222

40. Questions Regarding RAC Appeals National Government Services (NGS) Clinical Provider Outreach and Education 1-800-338-6101

41. Tips on Coding and Documentation

42. Rules of Engagement Medical record documentation has always been the key to coding and reimbursement. MS-DRGs, HACs, POA and RAC audits heighten the need for clear, meaningful, and specific physician documentation. Old rule��If it isn�t documented, it wasn�t done.� New rule��If it isn�t documented, query the physician.� Best rule��Document it�clearly, meaningfully, and specifically!�

43. Improving Documentation (cont.) Focus of the audit and review process History and Physical (H&P) Discharge Summary Special Examinations (consultations and testing) Physician Orders and Progress Notes

44. Improving Documentation (cont.) Nursing Notes Surgical Procedures Rehabilitation and Respiratory Care Services Medical Necessity of Admission DRG Validation

45. Improving Documentation (cont.) A leading cause of noncompliance Incomplete medical records submitted to the QIO for review Requests for additional information forwarded to providers only if required to determine medical necessity or address quality concerns

46. Improving Documentation (cont.) History and Physical Lack of documentation of pertinent prior medical, social, family, medication, and surgical histories Lack of documentation of vital signs Review of systems not documented Discharge Summary Not present in the medical record

47. Improving Documentation (cont.) Necessity of Admission Abstracted using InterQual� inpatient guidelines Many reviewed records lacked documentation to justify inpatient admission Independent medical judgment applied by the physician reviewer during case review

48. Quality Net http://www.qualitynet.org Hospitals � Inpatient Tab RHQDAPU link CMS RHQDAPU page http://www.cms.hhs.gov/HospitalQualityInits/08_HospitalRHQDAPU.asp Reporting Hospital Quality Data Annual Payment Update (RHQDAPU) Resources

49. Retired Measures AMI-6 Beta blocker at arrival 2Q 2009 PN-1 Oxygen Assessment 1Q 2009 PN-5b Initial Antibiotic received within 4 hours 1Q 2009

50. New Measures for FY 2011 Update SCIP Infection 9: Postoperative Urinary Catheter Removal on Post Operative Day 1 or 2 SCIP Infection 10: Perioperative Temperature Management

51. New Structural Measures for FY 2011 Update Participation in a Systematic Clinical Database Registry for Stroke Care Participation in a Systematic Clinical Database Registry for Nursing Sensitive Care

52. Agency for Healthcare Research and Quality (AHRQ)�Claims Based Measures  Patient Safety Indicators (PSIs) Inpatient Quality Indicators (IQIs)

53. Proposed Changes for FY 2012 Stroke Measure Set VTE Measure Set Changes to the validation process

54. Care Transitions::Why Focus on 30-DayReadmissions?

55. Prevalence and Drivers Medicare data analysis 19.6% beneficiaries are re-hospitalized at 30 days 34% are re-hospitalized at 90 days 67% are re-hospitalized or deceased at one year 90% of readmissions were unplanned Cost to Medicare $17.4 billion

56. Prevalence and Drivers (cont.) Medical patients re-hospitalized at 30 days >50% had no bill for physician service between discharge and re-hospitalization Surgical patients re-hospitalized at 30 days 70% were re-hospitalized with a medical diagnosis

58. QIO Provided Care Transition Support Defining the problems Discharge process mapping Cause and effect Root cause investigation and verification Recommended solutions Action planning for improvement Evaluation and lessons learned Program modifications

59. Typical Failure Modes in the Transition Process Post-acute care follow-up Medication errors and/or adverse events Poor or incomplete discharge instructions Lack of follow-up appointment Follow-up scheduled too long after hospitalization Inadequate or lack of outpatient management Lack of social support Confusion over self-care instructions Lack of adherence to medications, therapies, medications, and diet

60. Targeted Areas for Improvement ? Communication ? Medication reconciliation ? Patient empowerment and self management skills ? Physician follow-up ? Plan of care

61. Care Transitions Models Care Transition Intervention�Eric Coleman, MD http://www.caretransitions.org/ Care Transition Model�Mary Naylor, PhD http://www.innovativecaremodels.com/care_models/21 Better Outcomes for Older Adults Through Safe Transitions (BOOST)�Mark Williams, MD, Society Of Hospital Medicine (SHM) http://www.hospitalmedicine.org/ResourceRoomRedesign/RR_CareTransitions/CT_Home.cfm Re-Engineered Discharge Design (RED)�Brian Jack, MD http://www.bu.edu/fammed/projectred/index.html

62. Measures of Success Global re-hospitalization and acute care hospitalization rates Patient experience on hospital performance at hospital discharge (HCAHPS) Physician follow-up visit prior to hospital readmission Provider adoption of measured interventions that show improvement

63. Summary Re-hospitalization signals a �sea of change� in health care. Physicians and health care providers are becoming increasingly accountable for coordinating care beyond their walls. Physicians and health care providers have a choice whether to wait and see what happens to them or to adopt a proactive strategy to create their future.

64. Questions? Roland A. Grieb, MD, MHSA rgrieb@inqio.sdps.org 812-234-1499 Extension 221