3 rd Annual Association of Clinical Documentation Improvement Specialists Conference

1. 3rd AnnualAssociation of Clinical Documentation Improvement Specialists Conference

2. From the Bedsideto the Business Side of CDI Natalie Leagan, RN, BSN, CCDS

3. Move to the business side! Documentation is the key to unlocking opportunity and reducing/preventing risk throughout your organization • The medical record can be your organization’s greatest asset as well as its greatest source of risk! • Let’s begin to move to the business side!

4. Healthcare as a business • Still all about patient care • But, it’s not the “good old days” • Healthcare is a significant part of our country’s economy • Same issues as any other business • Fraud, waste, abuse, mismanagement • Regulatory and compliance issues • Accountability to the patient, public, and other stakeholders • “Wall Street” to “Main Street”

5. CDI and the healthcare revenue cycle • Uniquely positioned to impact multiple issues related to revenue cycle • Documentation is the foundation of many aspects of the healthcare revenue cycle • Think outside of the box! • Beyond your department • It’s not only about CCs and MCCs anymore • No more silos

6. Healthcare revenue cycle 101 • General understanding of the healthcare revenue cycle is necessary before you can examine those areas which you might be able to support and impact • Allows an integrated rather than a silo-type approach to revenue cycle • Reduction in duplication and inefficiencies when there is a more integrated approach • Allows for a proactive approach to the issues and concerns that can have detrimental effects on the back end when they could have been handled on the front end

7. Healthcare revenue cycle 101Pre-encounter/encounter/post-encounter • Pre-encounter administrative/access management • Scheduling • Medical necessity determination* (inpatient vs. outpatient) • Preregistration • Registration and demographics • Insurance validation • Insurance verification • Precertification • Financial counseling • Point of service collections *Regulatory/compliance concern

8. Healthcare revenue cycle 101Pre-encounter/encounter/post-encounter • Patient-physician encounter • HIM* • Coding* • Charge capture • Charge entry • Charge description master • Billing master • Documentation/concurrent review* • Utilization review/medical case management* • ED/outpatient or PACU/direct admission • Admission process/discharge planning • Concurrent denials prevention/management • Length of stay/avoidable days *Regulatory/compliance concern

9. Healthcare revenue cycle 101Pre-encounter/encounter/post-encounter • Back-Office Administration/Post-Encounter • Claims preparation* • Claims submission • Third party follow-up • Self-pay follow-up • Rejection processing • Payment posting • Payment validation • Denials/appeals management* • Contracts* • Uncollectables management *Regulatory/compliance concern

10. Provider functions/tasks vs. Payer functions/tasks • Paper vs. technology (software/systems/intermediaries) • Can be resource intensive • IT—interoperability (for example, third-party administrators and the provider) • Evaluate processes and procedures throughout the organization!

11. Manage through the revenue cycle! • Proactive management as patient moves through the revenue cycle • Efficiency and reduced administrative costs • Accurate/secure reimbursements • Timely information to payers • Timely evaluation of appropriate level of service • Reduced compliance risk • Improved patient quality of care • Core measures • Pay for performance • Communication • Patient advocacy • Actions by the provider affects patient’s financial obligations

12. Focus on: Inpatient • Traditionally, CDI programs have dealt with the following: • Accurate DRG assignments • CCs and MCCs? • **Not the primary driver of a compliant program • POA • HACs • Secondary diagnoses

13. Focus on: Inpatient • Medical necessity (screening) • CDI involvement? (could be a very good mix) • What about the ED? (examine all potential access points!) • Case management vs. HIM—the age-old debate (Not really that old, but it could be worth revisiting for the sake of the organization) • Each organization is unique in so many ways, look at the possibilities—maybe it is simply a matter of sharing expertise on committees, presenting education, or being the subject expert)

14. Focus on: Inpatient • Appropriate orders for level of care, documentation of medical necessity • Documentation of medical complexity in the record is key • www.medicareadvocacy.org/InfoByTopic/ObservationStatus/10_02.18.ObservationDecisions.htm • www.medicareadvocacy.org/ALJDecisions/ALJSearch.asp • Database of ALJ/MAC decisions • Helpful to formulate an appeal • Will give you the rationale upon which successful appeals were built • www.medicareadvocacy.org/InfoByTopic/ObservationStatus/Decisions/VT_ALJ_01.10.pdf (example) • www.medicareadvocacy.org/InfoByTopic/ObservationStatus/Decisions/MN_Maximus_11.09.pdf (example) • Condition Code 44 (admitted inpatient but never met necessity) • Four conditions must be met

15. Focus on: Data quality • Garbage in, garbage out • Are the data valid, accurate, a true reflection of what has occurred? • How can you improve the data as a documentation specialist? • Power is in the pen • “Mighty Mouse” • Are you automating a train wreck? • Integrate your expertise with the needs of other departments! • Look for opportunities! • Rounding, team meetings, departmental staff meetings, committees (compliance, IT, billing, denials management, case management, performance improvement, HIM) • Look for invitations to provide education to groups other than physicians (nursing, informatics/IT, billing, etc.)

16. Focus on: Outpatient • Medical necessity? • Outpatient services/procedures • Observation services • Observation services after an outpatient procedure • Observation services that precede inpatient admission • HOP-HACs (hospital outpatient healthcare-acquired conditions) • Not expanded to OPPS—yet! (P4P, VBP) www.hcprobootcamps.com/e-newsletter/detail/229886

17. Focus on: RACs • A new era of scrutiny! • Automated and complex reviews • Competence • Resource intensive and time-consuming • Cost • Additional expense (managing RAC response, appeals, etc.) • Need for technology—a spreadsheet just won’t do • Compliance • An opportunity to identify areas of risk and the impetus to do something about them! • Examine processes related to areas of risk—often these will cross multiple departments!

18. Focus on: RACs • Documentation underlies large areas of risk • Utilization review • Medical necessity (internal vs. external screening) • Clinical pathways/protocols may not be Medicare compliant! • CDI is key in the RAC response! • Audits?! Understand your organization’s policies for conducting audits • Physician education and communication • Future goal—RAC-proof your organization • What permanent changes have you made or need to make?

19. Focus on: MACs • MACs (Medicare administrative contractor) • Widespread probes • Example—Cahaba in Georgia https://www.cahabagba.com/ • http://search.cahabagba.com/search?q=widespread+probe&site=all&x=19&y=9&client=all&proxystylesheet=all&output=xml_no_dtd • https://www.cahabagba.com/part_a/whats_new/20071102_probe.htm • Pre-payment denials • Example—Cahaba in Georgia (CT scans, BNPs) • LCDs, NCDs • Example—debridement • www.cahabagba.com/part_a/policies_medical_review/lcd_active.htm • www.cms.hhs.gov/mcd/viewlcd.asp?lcd_id=30004&lcd_version=15&show=all

20. Focus on: MICs • MICs (Medicaid Integrity Contractors) • http://blogs.hcpro.com/revenuecycleinstitute/2009/07/medicaid-integrity-contractors-coming-to-a-hospital-near-you/ • www.cms.hhs.gov/DeficitReductionAct/Downloads/fy08cmip.pdf • www.healthleadersmedia.com/content/FIN-239174/Providers-Seek-Information-on-Medicaid-Integrity-Contractors## • www.dpw.state.pa.us/PartnersProviders/MedicalAssistance/DoingBusiness/FraudAbuse/003679192.htm(PA Department of Public Welfare) • www.ahcancal.org/events/calendar/MICAuditsAreHere/Document%20Library/1/MIP_MedicaidIntegrityContractors.pdf(American Health Care Association Webinar)

21. Focus on: ZPICs • ZPICs (Zone Program Integrity Contractor) • www.healthintegrity.org/html/contracts/zpic/index.html • One example of a MIC which serves TX, OK, CO, and NM for referrals of any suspected fraud, waste, or abuse in Medicare Parts A, B, DME, home health & hospice • Overview and description of case referral procedure on this Web site • Also an overview of the ZPIC program in general

22. Focus on: Commercial payers • Contracts vary, thus requirements also vary • The same company usually will have multiple products/policies, and contracts with providers can vary • Authorizations/pre-certs • Insufficient clinical information, inaccurate codes can result in denials • As goes Medicare, so go the commercial payers?

23. Focus on: Medicare BNI • Medicare Beneficiary Notices Initiative • ABNs, HINNs, Hospital Discharge Appeal Notices • www.cms.hhs.gov/BNI/ • Provides statutory guidance • www.cms.hhs.gov/BNI/12_HospitalDischargeAppealNotices.asp#TopOfPage

24. Focus on: MSP • Medicare Secondary Payer • Who other than Medicare could be responsible for payment? • Purpose is to shift costs away from Medicare to other sources of payment • MSP provisions www.cms.hhs.gov/manuals/downloads/msp105c01.pdf • Group health plans (working aged/spouse)? Workers’ compensation? Liability insurance? No-fault insurance? • Claim must first be submitted to the primary payer who is required to process and make payment per provisions of its contract. • Is there documentation in the chart which could indicate MSP applies? (a compliance issue and an opportunity for teamwork) • Will it change how the UR is managed? • Eligibility/verification/notification/pre-auth? • Oftentimes sensitive!

25. Focus on: Denials • Denials prevention/appeals process • Proactive in preventing denials rather than reactive in defending/appealing • Review of clinical documentation, coding, and billing is necessary to formulate an appeal • If you have to appeal, even if you win, you have lost!

26. Let’s talk compliance: CMS • HCPro www.medicarefind.com • Transmittalswww.cms.hhs.gov/Transmittals/01_Overview.asp • MLN Matters Articles (Medicare Learning Networkwww.cms.hhs.gov/MLNMattersArticles/ • CMS online manualswww.cms.hhs.gov/Manuals/ • Conditions of Participation (CoP), Conditions for Coverage (CfC) • Hospitals: www.cms.hhs.gov/CFCsAndCoPs/ • Physician documentationwww.cms.hhs.gov/MLNProducts/downloads/eval_mgmt_serv_guide.pdf

27. Let’s talk compliance: CMS • Medicare National Coverage Determinations Manualwww.cms.hhs.gov/Manuals/IOM/itemdetail.asp?filterType=none&filterByDID=-99&sortByDID=1&sortOrder=ascending&itemID=CMS014961&intNumPerPage=10 • Medicare Claims Processing Manualwww.cms.hhs.gov/Manuals/IOM/itemdetail.asp?filterType=none&filterByDID=-99&sortByDID=1&sortOrder=ascending&itemID=CMS018912&intNumPerPage=10 • Open Door Forumswww.cms.hhs.gov/OpenDoorForums/05_ODF_SpecialODF.asp

28. Let’s talk compliance: OIG • OIG compliance program guidance for hospitals • Composed of seven key elements based on federal sentencing guidelines (Exhibit 1) • http://oig.hhs.gov/authorities/docs/cpghosp.pdf • Self-disclosure protocol • http://oig.hhs.gov/authorities/docs/selfdisclosure.pdf

29. Let’s talk compliance: Federal Register Federal Register www.gpoaccess.gov • U.S. Government Printing Office • Search the Federal Register (Executive)

30. Let’s talk compliance: Coding • Coding rules and guidelines • Adherence ensures compliance and quality of data • www.ahima.org/coding/compliance.asp • AHIMA, AHA, National Center for Health Statistics, and Centers for Medicare & Medicaid Services are the four Cooperating Parties which together clarify the ICD-9-CM medical coding guidelines

31. Let’s talk compliance: HIPAA • HIPAA privacy rules • HIPAA security rules • Electronic protected health information (ePHI) • Applies to ePHI that is created received, maintained, or transmitted • Accessible by authorized people and processes • Not altered or destroyed in an unauthorized manner • Can be accessed as needed by an authorized person • U.S. Department of Health and Human Services • HIPAA Security Series

32. Let’s talk compliance: HITECH • Health Information Technology for Economic and Clinical Health Act (HITECH) • Created under the American Recovery and Reinvestment Act of 2009 (ARRA) • $787 billion economic stimulus package which included the plans to move to EHRs by 2015 or risk penalties • IT policy/procedures • There are high stakes for noncompliance (Exhibit 2)

33. Let’s talk compliance: HITECH • Business associates of covered entities • Previously under HIPAA security rules, required only “satisfactory assurance” that BA was compliant with HIPAA security rules • Pts can request a reporting of all of their electronic disclosures • Providers need to provide an audit trail, which includes all disclosures even between clinical personnel • Breaches • An unauthorized disclosure or use of PHI requires notification of the patient • Detailed regulations regarding notification includes CEs, BAs, vendors, and third-party service providers • Public posting of breaches www.hhs.gov/ocr/privacy/hipaa/administrative/breachnotificationrule/postedbreaches.html

34. Let’s talk compliance: Qui tam • Qui tam (whistleblower) lawsuits (Exhibit 3) • Kyphon • St. Joseph’s Hospital of Atlanta • http://atlanta.citybizlist.com/lstg/lstgDetail.aspx?id=28608

35. Become the expert! • ACDIS is a good start, but try to join at least one other professional association and plan to attend at least one other conference during the year—even a local chapter meeting • Surf the net, become self-taught • Learn what are reliable and accurate sources—and what are not! • Regulatory vs. opinion (interpretation) • Books/e-mail newsletters/blogs/Web sites • Network with others (not just CDI professionals) • People you have met here at the conference • Other professionals at work • Blogs, etc.

36. Become the expert! • Webinars and online courses • Committees at work and within professional associations; always opportunity! • Find opportunities to speak at meetings or conferences; you are already an educator! • Learn about adult learning styles • Take courses—computer courses, online courses, certifications, and degrees • Try to find something that complements your previous experience and something that interests you!

37. Become the expert! • Learn to manage; you may not be a supervisor or manager, but find ways to acquire the skills • Managing teams (committees), projects, presentations, etc. • Look at new employment opportunities to expand your knowledge and experience • Look at consulting as a potential opportunity

38. Become the expert! • Don’t be afraid that you might fail! • Don’t be afraid that you might not succeed! • In every experience, look for what it has taught you and carry that along into your next opportunity. • You already have learned how to learn. Make that work for you to position yourself for the next opportunity as you move from the “bedside” to the “business side!”