Expanding Clinical Validation Into Outpatient CDI. At the completion of this educational activity, the learner will be able to:

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1 Expanding Clinical Validation Into Outpatient CDI Tara Bell, RN, MSN, CCDS, CCM Manager, CDI & UR Services United Audit Systems, Inc. Cincinnati, OH 1 Learning Objectives At the completion of this educational activity, the learner will be able to: Define the importance of clinical validation in the CDI arena Identify key definitions and practice guidelines that relate to clinical validation Define diagnoses in the outpatient setting that commonly require clinical validation Formulate compliant clinical validation queries Develop education material for establishing clinical validation education to CDI/coding staff and providers 2

2 Introduction to Clinical Validation 3 What Is Clinical Validation? Clinical validation involves a clinical review of a case to assess if the patient truly possesses the clinical condition(s) that are documented in the record. Recovery Auditor clinicians shall review any information necessary to make a prepayment or postpayment claim determination. Clinical validation is beyond the scope of DRG (coding) validation and beyond the skills of a certified coder. This type of review can only be performed by a clinician or may be performed by a clinician with approved coding credentials. Clinical validation is performed by a clinician (RN, CMD, therapist) Centers for Medicare and Medicaid Services,

3 What Is Clinical Validation? Simply: Clinical validation is a necessary component for claims submission. Claims for reimbursement are governed by CMS regulations and policies. Is the documentation/diagnosis clinically supported? 5 Clinical Indicators Lab and Diagnostic Test Results Physical Assessment Findings Imaging Results Vital Signs Treatment Plans 6

4 Why Has Clinical Validation Become a Focus for CDI? Coded data has now expanded beyond DRGs and analytical reporting of clinical scenarios Substantiate denied claims Increase in RAC, MIC denials Legality Malpractice, legal defense Ensure an accurate clinical picture of the patient across the healthcare spectrum Proactive vs. reactive approach 7 Agencies & Laws Centers for Medicare and Medicaid Services (CMS) Recovery Audit Contractors (RAC) Statistics Data and Systems/Monitoring Programs The False Claims Act American federal law that imposes liability on persons and companies who defraud governmental programs. It is the federal government s primary litigation tool in combating fraud against the government. Fraud Enforcement and Recovery Act Submitting for payment or reimbursement on a claim known to be false or fraudulent 8

5 Compliance and Practice Guidelines 9 Practice Guidelines for CDI Professionals Official Guidelines for Coding and Reporting (OCG) Section I.A.19 titled Coding Assignment and Clinical Criteria Provider s diagnostic statement ACDIS Code of Ethics Ethical Standards for Clinical Documentation Improvement (CDI) Professionals (2016) Based on CMS guidelines, it appears clinical validation may be most appropriate under the purview of the CDI professional with a clinical background (AHIMA, July 2016) RAC Statement of Work by CMS 10

6 Coding and Reporting Guidelines: Outpatient ICD 10 CM/PCS Official Guidelines for Coding and Reporting for 2018 Section IV. Diagnostic Coding and Reporting Guidelines for Outpatient Services For accurate reporting of ICD 10 CM diagnosis codes, the documentation should describe the patient s condition, using terminology which includes specific diagnoses as well as symptoms, problems, or reasons for the encounter. There are ICD 10 CM codes to describe all of these. 11 CDI Responsibility Surrounding Clinical Validation What is our responsibility? Our #1 goal is to facilitate a clean and accurate reflection of the documentation and treatment of patient care Proactively work toward preventing questionable diagnoses and denials, and develop a plan Education, meetings, discussions, committees, etc. Seek clarification The updated AHIMA 2016 Query Practice Brief states that when there is a diagnosis without supporting clinical indicators, a query should be sent to the provider 12

7 Guidelines for Achieving a Compliant Query Practice (2016) The generation of a query should be considered when the health record documentation: Is conflicting, imprecise, incomplete, illegible, ambiguous, or inconsistent Describes or is associated with clinical indicators without a definitive relationship to an underlying diagnosis Includes clinical indicators, diagnostic evaluation, and/or treatment not related to a specific condition or procedure Provides a diagnosis without underlying clinical validation Is unclear for present on admission assignment AHIMA Practice Brief. "Guidelines for Achieving a Compliant Query Practice (2016 Update)" (Updated January 2016) 13 Compliant Query for Clinical Validation Apply the same process you would to capture a missing or vague diagnosis. Identify the indicators that support your question and the answers relevant to these indicators. Begin by listing the clinical indicators to support your query Know that your indicators may actually be a lack of indicators Normal labs/diagnostics Lack of supporting symptoms or patient presentation Lack of appropriate treatments/medications Lack of monitoring, evaluation 14

8 Documentation Criteria in the Outpatient Setting 15 Inpatient CDI Focus Goals Enhanced/correct MS DRG assignment Capturing accurate SOI/ROM for profiling Correct reporting of quality measures An accurate, clean, and complete chart Risk adjustment Measure SOI ROM Mortality data Quality measures (PSIs, etc.) Length of stay (LOS) Hierarchical Condition Categories (HCC) 16

9 Outpatient CDI Focus Traditional focus has been on obtaining one diagnosis to meet medical necessity for the visit One and done Focus has shifted for risk adjustment Now we are reviewing all conditions/diagnoses Involves many payment types (CPT, E/M, etc.) Hierarchical Condition Categories (HCC) OPPS guidelines 17 Understanding of Outpatient Risk Adjustment Definition of risk adjustment Statistical process payment methodology Underlying health status of a patient Prediction of healthcare costs future medical expenditures Disease burden determines the complexity of the patient Acute, chronic, status Settings & services not used for HCC diagnosis capture (risk adjustment) Freestanding ambulatory surgery centers SNF, hospice, home health Ambulance, lab, radiology, DME, prosthetics, orthotics, and supplies 18

10 Understanding of Risk Adjustment: Further Guidelines Documentation must reflect the diagnosis and the medical decision making process Diagnosis must have received management/treatment during the encounter Diagnosis must be applicable to the patient Avoid documentation of history of Currently being treated Malignancies can be tricky and often need clarification requires current treatment, monitoring, etc. 19 Inpatient vs. Outpatient CDI Inpatient Chart review at a much slower pace for capture of diagnoses affecting SOI/ROM Timeframes for visits are longer Concentration on case mix index, major comorbidities (MCC) and comorbidities (CC) CDI s goal is to optimize MS DRG assignment by capturing MCCs/CCs Payment models linked to value based care, incentives and penalties for hospital acquired conditions CDI queries make a positive MS DRG & APR DRG difference (can see potential dollars gained instantly) Outpatient All diagnoses (acute, chronic, screening, wellness) should be clearly documented and connected to the chief complaint (need clear reason for visit) Multiple different payment methodologies (E/M, CPT, etc.) and workflows (occurs at a faster pace) Focused on revenue protection and preventing denials Clearly documented medical necessity Will not see return on investment for 1 year Avoidance of underdocumenting or unclear documentation (affected by increased volume) Appropriate codes and sequencing are used for outpatient reporting CDI optimizes RAF score by capturing HCCs 20

11 Coding Guidelines: Outpatient Documentation First listed diagnosis Reason for encounter No impact on reimbursement Requires evaluation and management (E/M) level 10 levels that determine reimbursement Use of terminology for uncertain diagnosis Unable to code (probable, likely, etc.) Probable Likely Suspected 21 Challenges for Providers: Comparison Inpatient Assignment of principal diagnosis Documentation of all acute conditions Documentation of all chronic conditions DRG determined by PDX and comorbidities Comorbid conditions (CC) Major comorbid conditions (MCC) Use of probable, suspected, unable to rule out C OC MO MP PA AR RE DE D T OT O Outpatient physician office Reason for encounter Documentation of all conditions MEAT criteria HCC payment methodology Risk adjustment (HCC) Cumulative Chronic disease usually drives costs Can only use confirmed diagnoses or symptoms if diagnosis unconfirmed 22

12 Substantiate Clinical Criteria Before Claim Submission Documentation CDI Coding Claims Payer Audits Denial or Approval 23 MEAT Criteria Chronic conditions that have MEAT criteria (only one required) Monitoring of the disease or condition Signs Symptoms Disease progression/regression Evaluation of the disease or condition Test results Response to medication and/or treatment Assessment/Addressing of the disease or condition Discussions Counseling Ordering tests Treatment of the disease or condition Medication Referral Therapy, planned surgery, etc Outpatient CDI Pocket Guide 24

13 TAMPER Criteria Ensure there is at least one element of TAMPER documented for each coded condition T A M P E R Treatment Assessment Monitor/Medicate Plan Evaluate Referral 25 Common Diagnoses in the Outpatient Setting CKD CHF DM Malignancy BUN Creatinine Baseline labs Stage Systolic Diastolic EF Recent echo Type 1 Type 2 Insulin Complications Current Remission Being treated Primary Secondary 26

14 Education 27 Team Approach CDI Quality Team Approach Coding Providers 28

15 Education for CDI Professionals Know which diagnoses are being targeted research Query as appropriate Develop collaborative relationships amongst the team Utilize your internal escalation policy Establish regular multidisciplinary committee meetings to discuss cases for education Review previously denied claims for educational purposes 29 Tools to Assist With Querying the Provider Guidelines for Achieving a Compliant Query Practice (AHIMA in association with ACDIS) stresses the importance of clinical indicators. It is advised that queries be generated when a diagnosis does not appear to be supported by clinical indicators within the medical record. It is the provider who is ultimately responsible to determine which diagnoses are applied to the patient based on any clinical indicators they determine to be applicable. 30

16 Educational Tools for CDI/Coding Staff Training that provides: Continued education on identifying clinical indicators to support diagnoses and treatment Case scenarios for identifying documentation or diagnoses in the medical record that could be challenged for reimbursement or denials Access to online competency tools for continued education (CEUs) and certification Develop compliant query templates for reference and compliance CDI and coding pocket guides for references related to difficult diagnoses AHA Coding Clinic; CMS guidelines Specific diagnostic criteria (ASPEN, KDIGO, sepsis, etc.) RAC audit findings on previously denied claims Q&A sessions 31 Educational Tools for Providers Materials and handouts for reference CDI and coding pocket guides for references related to difficult diagnoses Web based CPT & E/M coding education In service education by the HIM/quality department on: DRG vs. clinical validation HCCs/RAF vs. case mix index/soi/rom CMS and AHIMA guidelines (for hospital classification systems and differing payment methodologies) RAC audit findings on previously denied claims Review of case scenarios to identify inadequate documentation requiring clinical validation Q&A sessions 32

17 Support for Providers Share up to date CDI resources with providers At the elbow support! Promote collaboration with pertinent team members 33 Escalation Policy Keep in mind that an escalation process for clinical validation is good practice If there is a discrepancy regarding the validity of a diagnosis, have a second level review or physician champion review Create an internal escalation policy for issues that remain unresolved CDI supervisor/site lead Physician champion Multidisciplinary committee (MDs, compliance, CDI staff) can review cases submitted when there is a mismatch between the clinical picture and diagnoses 34

18 Education Case Scenarios 35 Case Scenario #1: Diabetes 66 year old male seen in office on for regular checkup. Office visit states: DM type 2 today s exam consistent with no nonproliferative diabetic retinopathy in eyes. No DME. Patient has history of alcohol abuse and HTN. Most recent A1C of 8.1. Discussed importance of well controlled glucose and blood pressure to prevent complications of diabetes in the eyes. Diagnosis noted for the encounter: Diabetes mellitus type 2 with mild nonproliferative diabetic retinopathy without macular edema hyperglycemic bilateral. 36

19 Case Scenario #1: Diabetes Query Dear Doctor, Patient in for recent office visit on Office visit exam noted consistent with no nonproliferative diabetic retinopathy in the eyes Discussed importance of well controlled glucose and blood pressure to prevent complications of diabetes in the eyes. Diagnosis for the visit noted: Diabetes mellitus type 2 with mild nonproliferative diabetic retinopathy without macular edema hyperglycemic bilateral. Please further clarify if the patient currently meets the clinical criteria for: Diabetes mellitus type 2 with mild nonproliferative diabetic retinopathy without macular edema hyperglycemia bilateral Diabetes mellitus Type 2 with hyperglycemia Other Unable to further clarify 37 Case Scenario #2: Diabetes 78 year old female seen in office on Office visit notes: USA s/p DES & known CAD, HTN; DM 2 with other circulatory complications. Continue aspirin but reduce dose to 81 mg daily. Continue beta blocker, statin. Diagnosis for the encounter: Diabetes type 2 with other circulatory complications. 38

20 Case Scenario #2: Diabetes Query Dear Doctor, Patient in for recent clinical visit on Office visit noted USA s/p DES & known CAD, HTN; DM 2 with other circulatory complications. Continue aspirin but reduce dose to 81 mg daily. Continue beta blocker, statin. Please clarify the diagnosis of DM 2 with other circulatory complications by linking the other circulatory complication to the diabetes, based on the above notes. 39 Case Scenario #3: Malignancy 71 year old male seen in office today. Office visit states: Prostate cancer S/P radical prostatectomy one year ago. Also with HTN. Continue medication for HTN Lisinopril 10 mg PO daily. Diagnosis noted for the encounter: Malignant neoplasm of prostate. 40

21 Case Scenario #3: Malignancy Query Dear Doctor, There is a recent clinical visit on Office visit exam noted S/P radical prostatectomy one year ago. Also with HTN. Continue medication for HTN Lisinopril 10 mg PO daily. Diagnosis for the visit noted: Malignant neoplasm of prostate. Please further clarify if the patient currently meets the clinical criteria for: Malignant neoplasm of prostate Personal history of prostate cancer (no longer receiving active treatment) Other Unable to further clarify 41 Outpatient CDI Resources Resources regarding clinical validation ACDIS white paper: Clinical validation and the role of the CDI professional Official Guidelines for Coding and Reporting: ICD 10 CM Coding Guidelines.pdf AHIMA: Guidelines for Achieving a Compliant Query Practice (2016 Update) ACDIS: Outpatient clinical documentation improvement: An introduction ACDIS: Expansion of clinical documentation improvement to outpatient and physician services: A growing trend 2018 Outpatient CDI Pocket Guide: Focusing on HCCs 2018 CDI Pocket Guide CMS.gov ACDIS Code of Ethics RAC Statement of Work by CMS 42

22 References AHIMA. Guidelines for Achieving a Compliant Query Practice. Journal of AHIMA 84, no.2 (February 2013): Centers for Medicare and Medicaid Services. Prepayment Review Demonstration. December Statistics Data and Systems/Monitoring Programs/Recovery Audit Program/RecoveryAuditPrepaymentReview.html. Centers for Medicare and Medicaid Services. Statement of Work for the Recovery Audit Program DRG Validation vs. Clinical Validation Image Slide 33: Official ICD 10 CM/PCS Coding and Reporting Guidelines for Pinson, R. & Tang, C. (2018) CDI Pocket Guide. HCPro. Pinson, R. & Tang, C. (2018) Outpatient CDI Pocket Guide Focusing on HCCs. HCPro. 43 Thank you. Questions? Tara Bell Tara.bell@uasisolutions.com In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section at the front of the program guide. 44