"Stayin' Alive" in today's healthcare market: Bettering your observed to expected mortality rates

2. "Stayin' Alive" in today's healthcare market: Bettering your observed to expected mortality rates Terri Adell, RN, MS, CNRN, CCM Clinical Documentation Specialist Supervisor Stony Brook University Medical Center Catherine Morris, RN, MS, CCM, CMAC Executive Director of Care Management Stony Brook University Medical Center

3. Stony Brook University Medical Center 591-bed academic medical center Level 1 trauma center Regional stroke center, neuroscience institute Pediatric emergency room Comprehensive psychiatric emergency room Burn center Located in Stony Brook, Long Island, NY > 30,000 inpatient discharges/year

4. Objectives • Define severity of illness and risk of mortality • Discuss the risks and benefits of the current public reporting systems • Describe how to develop a mortality review program • Understand the benefits of using a risk-adjusted system • Describe some of the intricacies of coding certain patient types

5. Current Issues in Healthcare • High cost of services, push for reform and cost containment • Change to severity-based reimbursement • Decreased revenues due to MS-DRGs and RAC initiatives • Public access to physician/hospital report cards/outcomes • Change to ICD-10

6. New Focus: Risk Adjustment/Quality • Clinical documentation improvement programs initially focused on capturing major complications and comorbidities (MCC) and complicating conditions (CC) that impacted the DRG and that resulted in higher utilization of resources and higher reimbursement • SBUMC now uses a four-level subclass of APR-DRG data, which more accurately defines a patient’s severity of illness and risk of mortality: • Level 1: Minor • Level 2: Moderate • Level 3: Major • Level 4: Extreme

7. Benefits of Using a Risk-Adjusted System • Provides a higher level of specificity about the patients’ condition and the care/treatment provided • Improve facilities’ quality data • Improve physicians’ and hospitals’ public report cards • Enhance revenue, impact LOS • Ensure regulatory compliance • Avoid retrospective audit “money recovery” and penalties

8. CMS Severity Levels • MS-DRGs introduced October 1, 2007, to better account for severity of illness and resource consumption of Medicare beneficiaries • There are 3 levels of severity based on secondary diagnosis codes: • MCC (major complication/comorbidity), highest level of severity • CC (complication/comorbidity) • Non-CC does not significantly affect severity of illness and resource use

9. Definitions of SOI/ROM • Severity of illness: The “extent of physiologic decompensation or organ system loss of function experienced by the patient” (HCPro) • Risk of mortality: Likelihood patient will die from this illness The ratio of the SOI to the ROM = Mortality index

10. SOI ≠ ROM • Although severity of illness and risk of mortality are highly correlated for many conditions, they often differ because they relate to distinct patient attributes

11. Acute choledocholithiasis (acute gallstone attack) Severity of illness is major (level 2) (because of organ system dysfunction) Risk of mortality is minor (level 1)

12. If a more serious diagnosis presents, severity of illness and risk of mortality may increase – e.g., patient develops peritonitis as a complication of choledocholithiasis: Extreme (level 4) severity of illnessMajor (level 3) risk of mortality

13. Reasons for Mortality Reviews • Identify adverse events, errors • Prevention and process improvement • Documentation of core measure elements • Improve O/E severity of illness & risk of mortality • Revenue capture • Public reporting

14. Public Reporting Sites CMS’ Hospital Compare www.hospitalcompare.hhs.gov U.S. News & World Report www.healthgrades.com Thomson-Reuters www.100tophospitals.com Leapfrog Group https://www.leapfroghospitalsurvey.org UHC (University Healthsystem Consortium) https://www.uhc.com Premier, Inc. www.premierinc.com/quality-safety/tools-services/performance-suite/clinical-advisor.jsp State governments/DOH _______.gov In New York state: Myhealthfinders.com or NYSDOH.gov

15. Problems With Public Reporting • No standard data collection methods • Diverse data sources • Provider editing ability • Timeliness • Intent • Relevance, methodological rigor • Different measures of quality, inconsistent definitions used, different reporting periods • Institutional variability in the definitions

16. Improving Standardization Error- Prone Collection Methodology • Because mortality measures are obtained through claims rather than clinical data, we must work to improve the standardization of documentation and coding that drives mortality rates

17. Potential Problem Overcoding • There is always the risk of hospitals overcoding, either intentionally or unintentionally, and skewing results • Disclaimer: The information, techniques, situations, and references in this presentation are for information purposes only. They are not communicated with reference to any specific issue, do not constitute legal or clinical advice, and are not in any way a substitute for such due diligence inquiries and investigations as otherwise may be required by law or clinical standards. Laws, regulations, clinical standards, and other professional due diligence requirements vary from state to state. It is your responsibility to check with your compliance department before using any of the information/techniques from this presentation.

18. Our Mortality Review Processand Documents

19. Initially • Estimated yearly mortalities: 600 • Estimated reviewed records: 50 per month • One documentation specialist assigned to mortality review per week • Project length: Three months

20. Mortality Review Process– Documentation Improvement • Mortalities coded by HIM • Record “GROUPED” for severity and mortality risk by coder and second attestation printed and given to coding supervisor • Each mortality record placed on “MQ” bill hold (if it is a SMART chart, it will be placed on “MR” bill hold as usual until the record is reviewed by the coding supervisor and will then be changed to “MQ”) • Chart sent to tech park for scanning by coder • Report on mortalities run by coding supervisor daily to be picked up by CDS with attached attestations • Assigned CDS reviews records daily (Mon–Fri) • No query identified, coding supervisor notified to removeMQ bill hold by CDS

21. Mortality Review Process– Documentation Improvement • Queries identified, physician contacted regarding query by CDS • If physician does not agree, coding supervisor notified to remove MQ bill hold by CDS • If he or she agrees, physician documents on HIM retro query form • CDS brings retro query form to coding supervisor • Appropriate coding changes are made by coding supervisor and an attestation is sent as a priority scan to tech park • Chart regrouped for severity and mortality risk • Bill hold removed • CDS maintains database to be sent to coding supervisor by e-mail by close of business every Thursday for reconciliation • Report run every month on changes to severity and mortality

23. Identified Opportunities • Data collection • Neonates • Short-stay deaths • Palliative care/“V” code • Assigning an attending

25. Neonates New York State Law • If there is documentation that the infant “drew a breath,” then the child must be encountered as a live birth and considered an inpatient mortality..

26. Definition of Stillbirth • A stillbirth is when a fetus that was expected to survive dies during birth or during the last half of pregnancy* *In the United States, the term stillbirth or fetal demise does not have a standard definition. For statistical purposes, fetal losses are classified according to gestational age. A death that occurs prior to 20 weeks' gestation is usually classified as a spontaneous abortion; those occurring after 20 weeks constitute a fetal demise or stillbirth. Many states use a fetal weight of 350 g or more to define a fetal demise.

27. More Confusion New York vs. California • However, not all states interpret the weeks of gestation in the same manner. • In California, 20 weeks' gestation is worded "twenty utero gestational weeks" and has therefore been interpreted to be 23 weeks from the last menstrual period. (Implantation in the uterus does not occur until 1 week after fertilization.) • In New York state, intrauterine fetal death (IUFD) includes a death at a gestational age of 20 completed weeks or greater, or if fetal weight is 300 g or more.

28. Neonates • When are neonatologists/pediatricians involved? • Under what week gestational age are they coded solely from the obstetrician's notes? • Neonatologist language • Apnea vs. acute respiratory failure

29. Short-Stay Patient Deaths • There are many difficulties to address: • Medical history • Assessment is focused on the problem • Etiology • No/incomplete diagnosis • “Unresponsive” • Lack of studies or clinical findings • Lack of indication for procedures • Who is the attending of record?

30. Short-Stay Patient Deaths • A 57 y/o patient was brought in as a Code H from an outside hospital s/p cardiac arrest and intubation. He underwent emergent stenting upon arrival. He was clearly extremely ill, and his death in the CCU within 24 hours of arrival was not unexpected. • This patient was coded as having a ROM of 1 (the lowest risk in a scale from 1–4).

31. Short-Stay Patient Deaths • The sickest patients who arrive as a code H and expire rapidly and only have a slim chart may end up with the lowest ROM if the right verbiage is not stated by an attending physician or NP. • Cardiac arrest should be queried for cardiogenic shock • Intubation as acute respiratory failure • Renal insufficiency as acute renal failure • Glasgow coma scale of 5 must be stated as coma  

33. Cath Notes

34. Palliative Care • Comorbidities • Lack of specific treatment • Palliative care – V667 • Top 9 diagnoses • DNR code – V49.86

35. V66.7 Code • Effective October 1, 1996 • Terminally ill patient receiving palliative care • Palliative care is an alternative to aggressive treatment – the focus is toward management of pain and symptoms • Care provided is dependent on the terminal illness • Always a secondary code – terminal condition is always the principal diagnosis • Comfort care, end-of-life care, and hospice care are synonymous terms • MD documentation must include these or similar terms

36. Hospice or Palliative Care Code Usage

37. Assign an Attending Physician

38. Mortality Progress Note • Improve documentation • Clarify cause of death • Include other diagnoses • Ensure attending is identified

39. Mortality Note

41. Case Study

42. Attestation Clinical documentation specialist queried for further clarification of primary diagnosis based on documentation of unresponsiveness and GCS of 5. Physician documented that the patient was in a coma secondary to large intracranial hemorrhage and cerebral edema. This increased the SOI and the ROM to 4.

43. Case Study This patient underwent CPR in the ED with futile outcome. Because of documentation of prior cardiac interventions et al., the SOI/ROM increased to 4/4.

44. Results

46. Mortality Observed and Expected

47. O/E Index

48. Severity of illness and risk of mortality are highly dependent on the patient's underlying clinical problems

49. Thank You Terri Adell tadell@notes.cc.sunysb.edu Catherine Morris cemorris@notes.cc.sunysb.edu

50. Hughes J. 3M Health Information Systems (HIS) APR™-DRG Classification Software—Overview. In Mortality Measurement. February 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/mortality/Hughessumm.htmThe History of Medical Coding John Landers, eHow Contributor. Mortality Rates as a Measure of Quality and Safety, “Caveat Emptor” Robert Klugman, MD,1, Lisa Allen, PhD,2, Evan M. Benjamin, MD,3, Janice Fitzgerald, MS,4, and Walter Ettinger, Jr., MD, MBA1 American Journal of Medical Quality OnlineFirst, published on January 21, 2010 as doi:10.1177/1062860609357467 Evaluation of Fetal Death Author: James L Lindsey, MD, Consulting Staff, Department of Obstetrics and Gynecology, Santa Clara Valley Medical Center; Assistant Clinical Professor, Department of Obstetrics and Gynecology, Stanford University School of MedicineCoauthor(s): Sultana L Sultani, MD, Resident Physician, Department of Obstetrics and Gynecology, Santa Clara Valley Medical CenterContributor Information and Disclosures Updated: Jan 18, 2011 Suggested citation Kowaleski J. State definitions and reporting requirements for live births, fetal deaths, and induced terminations of pregnancy (1997 revision). Hyattsville, Maryland: National Center for Health Statistics. 1997. Krumholz HM, Rathore SS, Chen J, Wang Y, Radford MJ. Evaluation of a consumer-oriented Internet health care report card: the risk of quality ratings based on mortality data. JAMA. 2002;287:1277-1287. Hofer TP, Hayward RA, Greenfield S, Wagner EH, Kaplan SH,Manning WG. The unreliability of individual physician “report cards” for assessing the costs and quality of care of a chronic disease. JAMA. 1999;281(22):2098–2105, pmid:10367820. Choosing The Best Hospital: The Limitations Of Public Quality Reporting Health Aff (Millwood). 2008;27(6):1680-1687 OB and Newborn Coding Guidelines Differ Patricia Maccariella-Hafey, RHIA, CCS, CCS-P Posted on: April 15, 2002 Review of Newborn Coding Guidelines Prepared by Ingenix staff Posted on: December 8, 2010 July 2009 Clinical and Health Affairs, Price and Quality Transparency - How Effective for Health Care Reform? By John A. Nyman, Ph.D., and Chia-hsuan W. Li, B.S.P.H. Jha AK, Epstein AM. The predictive accuracy of the New York state coronary artery bypass surgery report-card system. Health Aff (Millwood). 2006;25(3):844-55. Oliver J. Wang, MD; Yun Wang, PhD; Judith H. Lichtman, PhD, MPH; Elizabeth H. Bradley, PhD; Sharon-Lise T. Normand, PhD; Harlan M. Krumholz, MD, SM. "America's Best Hospitals" in the Treatment of Acute Myocardial Infarction .Arch Intern Med. 2007;167(13):1345-1351 Scott C. Williams, PsyD; Richard G. Koss, MA; David J. Morton, MS; Jerod M. Loeb, PhD Health Services and Outcomes Research Performance of Top-Ranked Heart Care Hospitals on Evidence-Based Process Measures . Circulation. 2006;114:558-564. Martin Marshall, Paul G. Shekelle, Robert H. Brook, Sheila Leatherman, Dying to Know: Public Release of Information about Quality of Health Care. RAND» Reports and Bookstore» Monograph Reports » MR-1255 Linda McKibben, MD, Teresa Horan, MPH,Jerome I. Tokars, MD, MPH, Gabrielle Fowler, MPH, Denise M. Cardo, MD, Michele L. Pearson, MD, Patrick J. Brennan, MD, and the Healthcare Infection Control Practices Advisory Committee* Guidance on Public Reporting of Healthcare-Associated Infections: Recommendations of the Healthcare Infection Control Practices Advisory Committee.