PEPPER- Not Just a Spice

1. PEPPER- Not Just a Spice Ronald Hirsch, MD, FACP, CHCQM, CHRI R1 RCM Inc.

2. Learning Objectives • At the completion of this educational activity, the you will be able to: • Spell PEPPER • Interpret PEPPER data • Act on PEPPER data

3. PEPPER • Program for • Evaluating • Payment • Patterns • Electronic • Report 

4. So call it the PEPPER, not the PEPPER Report • You are now a PEPPER expert • Thank you. Questions? 

5. Other PEPPER Facts • Prepared by TMF (Texas Medical Foundation) Health Quality Institute • Fee For Service Medicare only • If lots Medicare Advantage, your data may be insufficient for conclusions • Released Quarterly ~ 5-6 months after quarter for acute care; yearly for others- SNF, Hospice, Psych, CAH, IRF, LTCH, PHP, HHA • Fiscal Quarters- Q1- Oct-Dec, Q2- Jan-Mar, Q3-Apr-June, Q4- July-Sept • Data is always at least 6 months old • Need 11 or more cases in numerator to have data reported • Your internal data will rarely match PEPPER data • PEPPER only goes to you but all contractors have access to same data through FATHOM- First-look Analysis Tool for Hospital Outlier Monitoring (which providers cannot get)

6. What is an Outlier? • PEPPER determines outliers based on preset control limits. The upper control limit for all target areas is the national 80th percentile. Areas at risk for undercoding also have a lower control limit, which is the national 20th percentile. • If top 20% and bottom 20% are outliers, that leaves only 60% inliers. • Being an outlier is not necessarily bad. If your patients really are sicker than everyone else’s, you should be at or above 80th%ile.

7. 20% is not an outlier Just because you stand out from the crowd does not mean you don’t taste as good! The outlier ranges are very broad; don’t be afraid to be an outlier if you have compliant processes.

8. But if your numbers are too good…

9. Basic Orientation

10. Definitions Tab- Numerator and Denominator

11. Compare Tab- #, % (result) and %ile (compare) Green- under 20th %ile Red- over 80th %ile

12. Outlier Tab- for the C-suite Only 0 - Not High Outlier 1- High Outlier Blank- less than 11 in numerator

13. Pictures!!!!!

14. Numbers!!!!

15. Let’s look at some definitions- Stroke ICH- by DRG • Numerator- DRG 061 to 066, Denominator- DRG 061 to 069; difference is 067, 068, and 069- nonspecific CVA and TIA • Percent is high= too many acute strokes and/or too few nonspec stroke/TIAs • High sounds good to me- good documentation and not admitting TIAs as inpatient • Percent is low= too many nonspec CVA/TIAs and/or too few acute strokes • Why are TIAs inpatient? Can we improve documentation on nonspecific CVAs?

16. Let’s look at some definitions- Syncope- by MDC N: count of discharges for DRG 312 (syncope and collapse)D: count of discharges for medical DRGs in MDC 05 (circulatory system) (DRGs 280 through 316) • Numerator- DRG 312 syncope • Denominator- Major Diagnostic Category 05- circulatory DRGs • Forget percent here- who the heck is admitting syncope patients? If they are inpatient, did they stay two midnights? If they stayed two midnights, why? Are we sure there was no other diagnosis, like orthostatic hypotension or bradycardia?

17. Let’s look at some definitions- Circulatory System • Numerator- DRG 314-316 other circulatory diagnoses • Denominator- Major Diagnostic Category 05- circulatory DRGs • Google DRG 314-

18. ICD-10 Diagnoses in 314-316- partial list

19. Now what? • First, look at number of admissions on compare table or data tab. Is it even worth your time? • 12 admissions-no; 40 admissions- yes • Enlist your data analyst. Give time period, DRGs and ask for list of all admissions with length of stay of each. • Deep dive into the specific issue • PDx assigned right? Status right? Documentation complete?

20. Pneumonia- Two Measures • Respiratory Infections • N= 177-178 Complex pneumonias w/CC or MCC • D= All pneumonias 177-179, 193-195 • If high, overcalling simple pneumonia as gram neg or aspiration, or perhaps lots of SNF patients? • If low, look at simple pneumonia with long LOS- are they really complex? Look at 179 to find a CC

21. Pneumonia- Two Measures • Simple Pneumonia • N= 193-194 Simple pneumonias w/CC or MCC • D= All COPD and simple pneumonias- 190-192, 193-195 • If high, overcalling pneumonia on COPD patients with atelectasis? Some simple should be complex? • If low, treating COPD patient with antibiotics as pneumonia but not documenting, 195- can you find a CC?

22. Sepsis DRG 870-872 • Numerator- 870-872 • Denominator- 193-195- pneumonia, 207-208- resp with vent, 689-690- UTI, 870-872 • Lots of sepsis? Look at short LOS patients • GMLOS for 872 is 4.3 days (in 2020) so look at 2 or fewer days. • Deaths not excluded so could be a factor • Debate about what is sepsis is a separate issue but I want to see organ dysfunction. • Not much sepsis? Look at long LOS for UTI, vent, and pneumonia patients • Did docs miss documenting it? • Maybe it’s better to be low here to avoid clinical validation audit hassles

23. Unrelated OR Procedures • Why are you doing a TURP on a patient admitted with pneumonia? • If you have a lot, review some charts.

24. CC and MCC Capture- Medical and Surgical

25. Surgical CC/MCC Caveat • Total Joint Replacements! • But TKA, and soon THA, no longer inpatient only so a whole new controversy erupts

26. Show your CFO the Money! Show your CMO the GMLOS!

27. Where do you want your CC/MCC rate? • At the true rate based on your patient’s actual CCs and MCCs • Remember, your patients are sicker than everyone else’s! • If you are at or above 80th%ile, how do you know if there is a problem or your patients really are sicker? • For higher volume DRGs, compare your LOS to CMS GMLOS. • Single CC or MCC- “One and done” not allowed

28. Inpatient or Observation • If you are high on these measures, look at the short stays (should they have been Obs?) and the long stays (a more specific dx?) • TIA • COPD • Syncope • Circulatory system disorders • Digestive system disorders • Medical Back

29. The Oddball Ones • Excisional Debridement- is “excision of tissue” documented? • Ventilator Support- % of patients on vent who were on > 96 hrs. • If high, check how intubation and extubation time entered and coded • Perc CV Px- % of cardiac stents done as inpatient • Elective- outpatient; MI or transfer- inpatient ok • Spinal Fusion- % of fusions c/w all spine surgeries • Are surgeons documenting necessity for fusion over simple laminectomy? • 3-Day SNF- % of patients who went to a SNF who spent 3 inpt days

30. Facility Billing 99385- Pts Not Admitted Inpatient

31. No Guidelines from AMA/CPT/CMS “Until national guidelines are established, hospitals should continue using their own internal guidelines to determine the appropriate reporting of different levels of clinic and emergency department visits. We would not expect individual hospitals to necessarily experience a normal distribution of visit levels across their claims, although we would expect a normal distribution across all hospitals as currently observed and as we would also expect if national guidelines were implemented. We understand that, based on different patterns of care, we could expect that a small community hospital might provide a greater percentage of low-level services than high-level services, while an academic medical center or trauma center might provide a greater percentage of high level services than low-level services.” 72 FR 66789

32. Readmissions- All Diagnoses • 30-day Readmission to Same Hospital or to any Hospital • Excludes transfers, AMA, planned readmission, second admit to psych or rehab • Let your readmission reduction team handle this- you have enough to do without readmission reduction (which actually loses you money)

33. Short Stays- Medical and Surgical • Percent compared to total number of admissions • Counts only Inpatient days • Time as outpatient in ED, OR, RR, Observation, Ext Recovery not counted • Excludes AMA, death, transfer admissions • Excludes Occurrence Span Code 72 admissions– Use it or lose! • Patients who spent one or more midnights as outpatient but total of two or more midnights in hospital • One MN in ED, one MN as inpatient, home on day 3 • One MN in ED, one MN as Obs, admit on day 3 then home same day • One MN in recovery, one MN as inpatient, home on day 3 • Two MN in recovery (MD forgot to admit), admit on day 3 then home • (assumes medical necessity for second MN)

34. Short Stays- Medical • 2 DS Med DRG- inpatient for 2 midnights • That’s a compliant admission, unless you are gaming. • 1 DS Med DRG- includes inpatient for 0 or 1 day • If zero inpatient days, that’s very one remarkable recovery. • If one inpatient day, should be unexpected rapid recovery or case-by-case exception • Can be high because you’re not yet using OSC 72 • If really low, are you too conservative with admissions?

35. Short Stays- Surgical • 2 DS Surgical DRG- inpatient for 2 midnights • That’s a compliant admission, unless you are doing non-inpatient surgery as inpatient and keeping two days for $ • 1 DS Surgical DRG- includes inpatient for 0 or 1 day • If inpatient only, that’s fine • If not inpatient only and home same or next day, that’s a problem, unless they are TKRs (but that’s a separate talk)

36. Top 1 DS- Medical and Surgical • One year data- 0-1 day inpatient LOS, same exclusions • Look at # of pts and percentages • If lots of patients or high percentage, audit • Surgical- watch for inpatient only • Can’t tell by DRG but can guess by name • Can refer to jurisdiction table to compare to others • Good for looking at length of stay

37. Top 1 DS- Medical DRGs

38. Top 1 DS- Surgical DRGs

39. Jurisdiction Example • What? 1,245 chest pain, 869 syncope, and 859 TIA patients admitted as inpatient and stayed one day? Who says we are all following the rules?

40. Medicare Spending Per Beneficiary

41. Medicare Spending Per Beneficiary

42. Summary • Don’t call it the PEPPER report • Look at the Compare tab first • Don’t let the red Outlier lines scare you • Look for opportunities to improve compliance and improve finances

43. Questions? • Ronald Hirsch, MD • Rhirsch@R1RCM.com