Destination Excellence – Driving Accountability

1. Dedicated to Hope, Healing and Recovery Destination Excellence –Driving Accountability Clinical Documentation Improvement Initiative: The Physician: What’s in it for Me? Hassan Alkhouli, MD, FCCP, CCS, CDI Physician Advisor Southern California District Wendy De Vreugd, RN, BSN, PHN, FNP, CCDS, MBA Senior Director of Case Management, Kindred Healthcare Hospital Division, West Region

2. Topics • So what’s the Urgency? Recovery Audit Contractors (RACs), Physician, and Hospital Profiling • Understanding the Clinical Documentation Improvement Specialist (CDIS) role • Introducing the Physician Query process • To the Physician: Communicate What’s in it for Me?

3. RAC Work Flow to Identify Errors Most improper payments occur when providers submit claims that don't comply with Medicare coding rules or medical necessity guidelinesMajor RAC Focus are the following; • 42% Incorrect Coding: $331.8M • 9% No/Insufficient Documentation: $74.3M • 32% Medically Unnecessary: $391.3M • 17% Other: $160.2M

4. HOW CAN HOSPITALS HELP PHYSICIANS TO APPROPRIATELY DOCUMENT THE SEVERITY OF ILLNESS TO JUSTIFY THE CONSUMPTION OF RESOURCES ?

5. MS-DRG as of October 1, 2007 MCC

6. Bridge the gap between “clinical and economic language” ICD-9 codes Help the Physician document and report the practice of medicine Unobtrusive to the practice of medicine Serves as a resource to the practice of medicine. Serves as a conduit for “translation” and communication of quality care provided. Maintains compliance standards day-to-day. Assist the physician in maintaining compliance with DRG and E&M documentation requirements Educate physicians on how to better communicate medical decision-making in explicit medical record documentation Clinical Documentation Improvement Programs - Query Physicians for Specificity • Allow the physician to maintain focus on the practice of medicine

7. Physician-Friendly Terminology Breaking the language barrier…

8. Physician Documentation –Inherent Concerns Accurate coding without querying is sometimes impossible! •Aside: Apology on behalf of physicians everywhere…

9. Insufficient, Incomplete, or Illegible Documentation How’s this patient doing? Good! Dated & Timed What is the medical complexity of this visit for billing? Understand the Plan?

10. CDI Specialists will “Query” Physicians Note: American Health Information Management Association (AHIMA) definition of Physician Queries: • Questions asked to physicians to obtain additional, clarifying documentation to improve the specificity and completeness of the data used to assign diagnosis and procedure codes... AHIMA. Managing an Effective Query Process.Journal of AHIMA79, no.10 (October 2008): 83-88

11. CMS defends hospital querying incentives “We do not believe there is anything inappropriate, unethical or otherwise wrong with hospitals taking full advantage of coding opportunities to maximize Medicare payment that is supported by documentation in the medical record.” “Hospitals’ efforts to improve the specificity and accuracy of documentation and coding are perfectly legitimate.” CMS: CMS-1533-FC:208 http://www.cms.hhs.gov/AcuteInpatientPPS/downloads/CMS-1533-FC.pdf Medicare Payment Advisory Commission: Letter to Acting Administrator Leslie Norwalk, June 11, 2007:12

12. Situations Warranting Queries AHIMA states that queries may be made in the following situations: • For clinical indicators without documentation of the diagnosis • When clinical evidence suggests a higher degree of specificity or severity • For a cause-and-effect relationship between two conditions or organisms • For an unstated underlying cause when admitted with symptoms • For a diagnosis when only the treatment is documented • To establish present on admission (POA) status

13. Query when needed to clarify: “…conflicting, incomplete, or ambiguous documentation…or POA status…” “…accuracy of code assignment and quality of health record documentation...” “…unclear clinical significance (compression fracture—new or old?)” “…illegible, incomplete, unclear, inconsistent, or imprecise [documentation]…”

14. What’s in it for me?….Let’s Talk About “My Patients are Sicker”...

15. MS-DRGs (Medical Severity) Primarily Resource Intensity-based The basic MS-DRGs are used by the Centers for Medicare and Medicaid Services (CMS) for hospital payment for Medicare beneficiaries 3M APR-DRG (All Patient Refined) Expansion of the basic DRGs to be more representative of non-Medicare populations The All Patient Refined DRGs (APR-DRG) incorporate severity of illness and risk of mortality subclasses; prognosis and treatment difficulty Use of DRG Systems

16. Physicians Note DRG classification is not only for purposes of reimbursement… But captures the documentation necessary for quality of care analysis and mortality predictions for both you…and the hospital!

17. 3M™ APR DRG Classification System

18. Definitions of the Sub-Classes • Severity of Illness (SOI): The extent of physiologic decompensation or organ system loss of function • Each APR DRG SOI has a relative weight assigned to it to reflect resource consumption • Risk of Mortality (ROM): The likelihood of dying in the admission

19. Level of Severity of Illness & Risk of Mortality Can Be Different • A patient with acute cholecystitis may have a significant amount of organ decompensation, but a low risk of dying: • SOI: 3 • ROM: 1 • While unlikely to die, such cases can be resource intensive. In internal QI work, patients with a ROM of 1 or 2 who expired could be an area of focus.

20. Calculation of Mortality Rate “Gap”

21. Impact of Complete Documentation Have reached the highest MS-DRG. Changes ROM Changes Severity Of Illness (SOI) and MS-DRG Changes Risk Of Mortality (ROM) Changes SOI and MS-DRG

22. Sensitivity to Illness Burden & Risk of Mortality Sensitivity to Illness Burden & Risk of Mortality: An Example PRINCIPAL DX: CONGESTIVE HEART FAILURE CASE 1 CASE 2 SECONDARY DIAGNOSIS COPD atrial fibrillation COPD atrial fibrillation respiratory failure acidosis decubitus ulcer malnutrition cardiogenic shock MEDICARE DRG APR DRG 127 Heart Failure & Shock 194 Heart failure 127 Heart Failure & Shock 194 Heart Failure APR DRG SOI 1 minor 4 extreme APR DRG ROM 1 minor 4 extreme APR DRG RELATIVE WEIGHT 0.07847 2.9128 MORTALITY RATE (APR DRG ADJUSTED) 1.7% 36.3%

23. Insufficient Documentation Insufficient documentation means that the provider did not include pertinent patient facts (e.g., the patient’s overall condition, diagnosis, and extent of services performed) in the medical record documentation submitted.

24. Bottom Line • Lack of complete and accurate diagnoses reporting on every daily progress note contributes to instances of “Insufficient documentation” • Examples include “Proceed as planned” “Doing Better” “No new complaints” “Stable, discharge in the morning”

25. Documentation Tips Severe Hypoxia (S&S) Urosepsis Uncontrolled NIDDM Severe COPD on continuous O2 Community Acquired Pneumonia and dysphasia, s/p CVA. Serum Na of 145 mEq/L Early or mild Acute Respiratory Failure UTI with Sepsis Type 2 DM with Hyperosmolarity, uncontrolled. Chronic Respiratory Failure Possible Aspiration Pneumonia -Community Acquired Hypernatremia Clinically Significant but Low SOI: Greater SOI Captured:

26. Beyond Reimbursement... Reimbursement Measure Efficiency & Effectiveness Quality Outcomes

27. QUESTIONS? Questions about this presentation? Please contact Wendy DeVreugd at Wendy.DeVreugd@kindredhealthcare.com