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Targeted Utilization Issues and Your Data

Targeted Utilization Issues and Your Data. Monty Bodenheimer, MD, Medical Director IPRO Richard Lee, MA, MPH, Sr. Data Analyst IPRO May 11, 2005. Today’s presentation:. Part I – Introduction New York State Payment Error Rate. Hospital Payment Monitoring Program.

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Targeted Utilization Issues and Your Data

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  1. Targeted Utilization Issues and Your Data Monty Bodenheimer, MD, Medical Director IPRO Richard Lee, MA, MPH, Sr. Data Analyst IPRO May 11, 2005

  2. Today’s presentation: Part I – Introduction • New York State Payment Error Rate. • Hospital Payment Monitoring Program. Part II – Clinical Issues and Suggestions • Appropriate for Orthopedic Specialists, etc. • Goal is understand clinical issues relevant to DRGs 243 and 253. • Q & A Part III - PEPPER Presentation • Appropriate for Compliance Officers, HIM and UR Directors, Data Specialists/Analysts, etc. • Goal is to be able to read and interpret PEPPER data using Target Area: 239, 243 and 253 as an example. • Q & A Part IV – Recap, Conclusions and Next Steps

  3. New York State Payment Error Rate

  4. Changes in Payment Error Trends Slight reduction for nation, drastic reduction for NYS. Stable for Nation, on the rise for NYS. Nation remains stable, NYS increase with erratic history.

  5. Why did we choose these DRG’s for today’s presentation? • DRG’s 253 and 243 are among the top admission denials for fiscal year 2004. • DRG 243 has been a top admission denial for two consecutive fiscal years. • CMS Target Area: DRG’s 239, 243 and 253 • This Target Area accounted for $50,638,869 in CMS payments in FY 2004.

  6. DRGS 243 & 253

  7. When is inpatient status appropriate? General Guidelines • Need for inpatient care is determined by a physician based on expectation that inpatient level of care will be needed for about 24 hours or more. • Consider: • Medical history and severity of symptoms/signs. • Inability to obtain procedures required to make a decision and the delay is NOT for patient, facility or physician convenience.

  8. When is inpatient status appropriate? General Guidelines • Inpatient care is NOT necessary if care could have been provided at lesser level of intensity without significantly and directly threatening the patient’s safety or health or when the admission is for convenience. • DOCUMENTATION MUST SUPPORT THE DECISION

  9. DRG 243 Medical Back Problems • Principal Dx: Examples 720.8 Spondylopathy 723.0 Stenosis, spinal, cervical region 723.9 Disorders, musculoskeletal, unspecified, and symptoms referable to neck 839.X Dislocations of …vertebra

  10. DRG 243 Medical Back Problems Patient Example: 40 yo woman, history of pseudotumor cerebri s/p shunts came to ER with low back pain for over a week, shooting pain down her leg and numbness in sacral area. In ER, iv toradol and morphine. Admitted and treated with PCA. Seen by neurology – left lumbosacral radiculopathy likely due to disc disease. DX: 724.4 Lumbosacral neuritis DRG: 243 Reviewer: Felt documentation in chart supported progressive radiculopathy or spinal cord problem. Admission approved.

  11. DRG 243 Medical Back Problems Patient Example: 83 yo woman came to ER from assisted living due to back pain, difficulty walking. Exam: slight pain on palpation. Neuro exam negative. X-ray: degenerative disc disease L4-5 and L5-S1. Plan: Admit and evaluate by PT/OT in AM. Discharged: day 2 DX: 724.5 Backache, unspecified DRG 243 Decision: Admission not justified.

  12. DRG 243 Medical Back Problems Patient Example: 82 yo woman, rheumatoid arthritis for years involving multiple joints came to ER with back pain, arms and hand swelling and increasing knee pain. Had been receiving injections of steroids and methotrexate. Exam showed minimal right knee swelling, initial Temp elevated, WBC normal. Afebrile next AM. Treated with percocet and po prednisone. Day 2: seen by orthopedics and treated with injections. Culture of knee day 3. No antibiotics at any time. Day 3: discharged DX: 723.0 Stenosis of cervical spine 714.0 Rheumatoid arthritis. Reviewer: “The condition may require admission but do not see information that indicates patient could not have been treated otherwise.” Admission denied.

  13. DRG 253 Fractures, Sprains, strains and dislocations of upper arm and lower leg except foot age >17 with CC • Principal Dx: Examples 717.X Derangement meniscus … 718.0X Disorder, cartilage, articular 811.0X Fracture, closed, scapula 811.1X Fracture, open, scapula 823 Fracture, tibia and fibula

  14. DRG 253 Fractures, Sprains, strains and dislocations of upper arm and lower leg except foot age >17 with CC Patient Example: 91 yo woman, history of afib, CHF came to ER after fall at home for second time. Xray showed fractured humerus. In ED, dehydrated. WBC elevated. BNP and Tn both elevated. INR 4.2 and rose to 5.2 next day and given Vit K and FFP. Fracture treated conservatively. DX: 812.09 Closed fracture of upper humerus. DRG: 253 Reviewer: Approved admission due to multitude of medical problems.

  15. DRG 253 Fractures, Sprains, strains and dislocations of upper arm and lower leg except foot age >17 with CC Patient Example: 90 yo woman, wheelchair bound, s/p hip replacement, post polio syndrome living with son presented on a Saturday with ankle fracture which by history had been present for several days. In ER, given MS and soft splint. Subsequently only oral meds for pain. Seen by orthopedist who applied a hard splint on day 2. Discharged on day 3. DX: 823 fracture upper end tibia-close. DRG: 243 Reviewer: While the decision to admit for possible social reasons are understandable, documentation in the chart does not justify the need for acute care.

  16. DRG 253 Fractures, Sprains, strains and dislocations of upper arm and lower leg except foot age >17 with CC Patient Example: 83 yo woman admitted with a comminuted fracture of the humerus. Hx of dementia, had left distal radius fracture 6 wks earlier. DX: 812.09 Closed fracture of upper humerus. Upper end. DRG: 253 Reviewer: No need for acute in patient care.

  17. PEPPER: A Conversation Continued

  18. Previous PEPPER Presentations • Download PEPPER Training recordings/slides: • IPRO website (www.ipro.org/pepper) • JENY - Medicare Payment Error & Case Review Initiatives (http://jeny.ipro.org)

  19. Previous PEPPER Presentation • January 2005 (also 2/2004) • PEPPER Defined • Organization of the report • Basic PEPPER Concepts: Numerator, Denominator, Percent, Median, Percentile • How to act on the information in PEPPER

  20. Review • “The Office of Inspector General’s Compliance Program Guidance for Hospitals” (1998) encourages hospitals to develop and implement a compliance program. • Tool developed by the Texas Medical Foundation - The Program for Evaluating Payment Patterns Electronic Report. • Help in prioritizing auditing tasks.

  21. Review • A major objective of a compliance program involves ensuring that charges for Medicare services are correctly documented and billed. • The identification and prevention of payment errors.

  22. Review • The report is grouped into 14 “Target Areas” as determined by CMS. • The proportion of cases in a given Target Area for your hospital is compared with the rest of the hospitals in the state. • Outliers are proportions at or above the 75th Percentile or below the 10th Percentile.

  23. Since last time… • “The Office of Inspector General’s Supplemental Compliance Program Guidance for Hospitals” (2005) • Continues to emphasizes the need for effective compliance programs. • Internal monitoring and auditing activities.

  24. Target Area: DRG’s 239, 243 and 253 • DRG 239: Pathological Fractures and Musculoskeletal and Connective Tissue Malignancy • DRG 243: Medical Back Problems • DRG 253: Fractures, Sprains, strains and dislocations of upper leg except foot age >17 with CC

  25. FY 2002 FY 2003 FY 2004 Q1 FY 2005 % Change FY 2002 to Q1 FY 2005 (Quarterly basis) Total: Percent (of all hospitals) 100 100 100 100 Count (of all hospitals) 199 194 189 187 Sum of TA Discharges 9,666 9,975 10,123 2,603 7.72% Sum of Total Discharges 701,919 707,108 715,009 185,155 5.51% Aggregate Percent 1.38% 1.41% 1.42% 1.41% 2.17% Avg. Medicare Payment 4,823 4,790 5,002 5,353 10.99% Sum of Medicare Payments 46,622,507 47,784,040 50,638,869 13,933,695 19.54% Target Area: DRG’s 239, 243 and 253 All New York State Acute Care Hospitals

  26. Percentage of hospitals for Target Area. Total number of hospitals with at least one discharge. Numerator Numerator Total number of Target Area discharges. Denominator Denominator Total number of discharges. Overall Target Area percentage. Average payment per discharge. Total of all payments. Target Area: DRG’s 239, 243 and 253 Q1 FY 2005 All New York State Acute Care Hospitals Total: Percent (of all hospitals) 100 187 Count (of all hospitals) 2,603 Sum of TA Discharges 185,155 Sum of Total Discharges 1.41% Aggregate Percent 5,353 Avg. Medicare Payment 13,933,695 Sum of Medicare Payments

  27. Hospital Specific PEPPER Data for Target Area: DRGs 239, 243, & 253 Numerator Denominator Denominator Numerator Measures FY 2002 FY 2003 FY 2004 Q1 FY 2005 Target area discharge count 86 115 102 34 Denominator count (All Discharges) 6,079 5,946 5,524 1,292 Percent (Target area count / Denominator) 1.41% 1.93% 1.85% 2.63% Target area Avg Length of Stay (ALOS) 5.3 6.1 6.1 5.1 Denominator Average Length of Stay (ALOS) 6.0 6.1 6.3 6.4 Target Avg Medicare Payment $3,231 $3,178 $3,486 $3,442 Target Sum Medicare Payments $277,851 $365,514 $355,545 $117,040

  28. Statewide Comparative Data for Target Proportion: Summary FY 2002 FY 2003 FY 2004 Q1 FY 2005 90th percentile 2.23% 2.30% 2.25% 2.63% Change from FY 2002 to Q1 FY 2005 Percent Point Change 75th percentile 1.85% 1.86% 1.84% 1.98% From FY 2002 To Q1 FY 2005 Median 1.37% 1.45% 1.48% 1.42% Hosp Proportion 1.41% 2.63% 1.22 10th percentile 0.70% 0.79% 0.85% 0.69% State Median 1.37% 1.42% 0.04 Hospital Specific PEPPER Data for Target Area: DRGs 239, 243, & 253

  29. PEPPER Examples 1 2 3

  30. What to do with outliers • Hospital Case Mix • Changes in Clinical Staff • Changes in Policies and Procedures • New Treatment Programs • Change in Population Demographics

  31. What to do with outliers • Take a random sample of current medical records. • Review to determine if documentation and/or billing errors exist. • You do not have to try to replicate the report. • Guide your current and future auditing activities with these data.

  32. What to do with outliers • Look for trends. • Be pro-active and preventative. • Identify root causes of payment errors when errors occur.

  33. Contact Info: You may pose additional PEPPER and/or target area questions directly to the JENY website (under the Medicare Payment Error & Case Review Initiatives) Website: http://jeny.ipro.org/ Website: http://www.ipro.org/pepper

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