Polling Question #1. Risk Adjustment in the Inpatient Hospital Setting

Transcription

1 1 Risk Adjustment in the Inpatient Hospital Setting Mark N. Dominesey, RN, BSN, MBA, CCDS, CDIP, CHTS CP Manager of CDI Children s National Medical Center Washington, DC 2 Polling Question #1 Does your facility educate inpatient physicians, coders, and CDI professionals on risk methodologies? Yes, we educate on APR DRG (SOI/ROM) only Yes, we educate on observed to expected ratios (O/E) in addition to SOI/ROM Yes, we educate on HCC based methodologies (MSPB, MA plans) in addition to SOI/ROM and O/E No, we do not educate physicians on risk methodologies at this time 3 1

2 4 Learning Objectives At the completion of this educational activity, the learner will be able to: Identify three risk adjustment schemes Describe the HCC risk adjustment scheme and which inpatient quality programs it impacts Detail at least five secondary diagnoses that impact inpatient risk adjustment Inpatient Risk Adjustment VS. My hospital s patients are sicker than their hospital s patients Oh brother, not again! My hospital s complication rate cannot be compared to their hospital s complication rate because my hospital s patients are at higher risk for adverse outcomes. Image source: 5 Why Should CDI Be Interested in Risk Adjustment? healthgrades publishes list their 100 best hospitals

3 7 Risk Adjustment Concepts Definition of risk adjustment A methodology used to adjust for clinically relevant patient factors outside of the hospital s control such as demographic characteristics, comorbidities, and patient frailty (think of handicapping ) Why is risk adjustment needed? Compares providers, organizations, and payers Encourages the continued documentation of resource intensive chronic conditions Ensures proper allocation of funds and resources for treatment Facilitates more accurate comparisons by accounting for differences in case mix Fee for Service Payment/PhysicianFeedbackProgram/Downloads/Risk Adjustment Fact Sheet.pdf fee for service payment/acuteinpatientpps/readmissions reduction program.html Risk Adjustment Concepts What is the intent of risk adjustment? To accurately reflect the health of the patient population, adjusting for outcome measures such as Mortality Readmissions Complications Length of stay Resource utilization Costs Fee for Service Payment/PhysicianFeedbackProgram/Downloads/Risk Adjustment Fact Sheet.pdf fee for service payment/acuteinpatientpps/readmissions reduction program.html 8 Methodologies That Use Risk Adjustment APR DRG Hierarchical Condition Categories CMS (Medicare) and HHS (ACA) (HCCs) AHRQ (PSI 90) Hospital Compare/Physician Compare University Hospital Consortium (UHC) Joint Commission s ORYX (Healthchek) Others (U.S. News, Truven, MedeAnalytics, CareScience, etc.) 9 3

4 10 Why the Focus on Inpatient Risk Adjustment? We capture CCs and MCCs! Isn t that enough? What? Are you joking? MS DRG is intended to be a reimbursement mechanism only MS DRGs only provide a limited ability to integrate risk adjustment one, two, or three tiers Once a comorbid condition (CC) or a major comorbid condition (MCC) is coded, there are no additional financial incentives to document more comorbid conditions Opportunity lost in increasing patient, provider, and hospital severity and risk Image Sources: Universally Accessible Risk Adjustment The APR DRG Risk Adjustment Model The All Patient Refined Diagnosis Related Group (APR DRG) model was created by 3M to provide greater insight into severity and risk across all populations The APR DRG system expands on MS DRGs to address patient severity of illness (SOI) and risk of mortality (ROM) Severity of illness (SOI) relates to the extent of physiologic decompensation or organ system loss of function Risk of mortality (ROM) relates to the likelihood of dying Both SOI and ROM are further divided into four subclasses: 1: Minor, 2: Moderate, 3: Major, 4: Extreme Patients with high subclass levels are usually characterized by multiple serious diseases or illnesses Like the MS DRG model, each APR DRG has a relative weight that can be used in CMI calculations 11 Constructing an APR DRG APR DRG Severity classification Base APR DRG Age Gender Discharge status Diagnoses Procedures Birth weight Four levels of each: Severity of illness (SOI) Risk of mortality (ROM) Source: us.ahrq.gov/db/nation/nis/apr DRGsV20MethodologyOverviewandBibliography.pdf, pg

5 13 Observed to Expected Mortality Image source: Why Measure Mortality? Patients Low mortality rates (expressed as mortality index) = high quality hospital or practitioner I want this practitioner or hospital to care for me they are better at preventing death High mortality rates = low quality hospital Is there something wrong with this hospital/practitioner? Public perception of O/E Publicly available Quality Measures are displayed in many publications and venues The public makes judgments based on old data (two years in some cases) so do quality agencies 14 Calculating Observed to Expected (O/E) Ratios Example: Mortality We will walk through using O/E for measuring mortality, but the concept applies no matter the outcome measured (mortality, readmissions, LOS, cost, severity, complications) The number, expressed as a fraction or a ratio, represents actual mortality rates to the expected rate of mortality for that practitioner, hospital, or organization. The "observed to expected mortality" rate is a risk adjusted measure of a hospital's mortality rate. This ratio is created from two sets of numbers: Observed mortality: The actual number of patients that died in the hospital each measured time period (month, quarter, year) Expected mortality: The expected average of hospitalized patient deaths with a particular illness or condition that are beyond the control of the practitioner or organization, such as age, gender, and other medical problems Observed mortality is divided by expected mortality to create the O/E ratio The meaning of an O/E ratio depends on the score: Equal to 1.5. The hospital's mortality rate is higher than expected. Equal to 1.0. The hospital's mortality rate is equal to what is expected. Equal to The hospital's mortality rate is 25% lower than expected. Equal to The hospital's mortality rate is 50% lower than expected. A lower score typically represents higher quality care 15 5

6 16 Denominator Issues Expected Mortality Influences: Patient acuity Expected mortality is calculated using a mathematical risk adjustment tool Robustness of risk adjustment calculation method Some are unable to capture demographic or psychosocial factors that influence mortality risk (e.g., lack of access to care) Reliability of methodology Comparison of risk adjustment models yields variable results APR DRG Mortality Drivers 17 Common Mortality Risk Adjustment Variables APR DRG ROM subclass for mortality SOI subclass for LOS and costs Patient age Patient sex Admit source = Transfer from another acute care hospital Transfer from skilled nursing Renal failure facility AIDS Long term care facility Obesity Low socio economic status Weight loss (based on Medicaid, self pay, charity as primary payer) Drug abuse Psychoses Admit status = emergency Patient race Agency for Healthcare Research and Quality (AHRQ) Comorbid conditions (not all inclusive): Congestive heart failure Pulmonary circulation disorders Hypertension (complicated and uncomplicated) Chronic pulmonary disease Diabetes (complicated and uncomplicated) Alcohol abuse Source: Depression patient safety/quality resources/tools/mortality/meurer.pdf 18 6

7 19 Condition Categories (Learning Example: HCCs) Image source: Where are HCCs Used in Inpatient Settings? Condition categories are used for risk adjustment in CMS quality initiatives including: Value Based Purchasing Program PSI 90 Medicare Spend Per Beneficiary (MSPB) HAC Reduction Program Hospital Compare 20 HCCs: Overview Demographic factors Carries a Risk Adjustment Factor (RAF) score Age Gender Disability status Condition Categories are diagnosis specific and each carries a RAF score Condition Categories group patients that are clinically similar (think DRGs) In some risk adjustment mechanisms, hierarchies are applied (e.g., multiple categories of diabetes, drop lower weighted category RAF) HCC risk adjustment is based on: Diagnoses RAF + Demographic (RAF) = Patient s RAF score 21 7

8 22 CMS HCC Risk Adjustment Model Patient presentation 69,000+ ICD 10 Codes 8,771 qualifying diagnoses 79 HCCs (CMS) Patient s Risk Adjustment Factor International Classification of Diseases specific diagnostic codes ICD 10 codes that contribute to HCCs Clinical syndromes with like or similar costs, outcomes, resource consumption Numeric calculation or normalization of patient s risk Risk Adjustment Example: CMS HCCs Selected ICD codes are grouped to a Condition Category ~ 8,800 ICD 10 CM codes Acute, chronic, or acute on chronic conditions ~ 75% are also MS DRG MCCs or CCs 79 Condition Categories in Version 22 model Each Condition Category has a risk value or weight/coefficient Risk values can change year to year For unrelated diseases, Condition Categories are cumulative e.g., a patient with heart disease, stroke, and cancer will have three separate Risk Adjustment Factors added together 23 HCC Risk Adjustment in Value Based Purchasing Medicare Spend Per Beneficiary (MSPB) is domainweighted for 25% of VBP (up to 0.5% penalty in 2017) MSPB is a publicly reported measure on Hospital Compare Broadly follows HCC version 22 Severity of illness is measured across 79 HCC indicators Look back period is 90 days before the encounter (to ascertain if beneficiary previously in long term care) Disease interactions are included Does not control for sex and race For unrelated diseases, Condition Categories are cumulative e.g., a patient with heart disease, stroke, and cancer will have three separate Risk Adjustment Factors added together Source: Fee for Service Payment/PhysicianFeedbackProgram/Downloads/2017 MSPBM MIF.pdf 24 8

9 25 MSPB Episode The period 3 days prior to an IPPS hospital admission (also known as the index admission ) through 30 days post hospital discharge Hospital admissions that are NOT considered as index admissions include: Admissions that occur within 30 days of discharge from another index admission Acute to acute transfers Episodes where the index admission claim has $0 payment Admissions having discharge dates fewer than 30 days prior to the end of the performance period Source: content/uploads/2016/06/mspb_slides_npc_2016may19_finalc508.pdf Calculating the MSPB Ratio MSPB amount: Sum of a hospital s standardized, risk adjusted spending across all of the hospital s eligible episodes divided by the number of episodes MSPB measure: A hospital s MSPB amount divided by the episode weighted median MSPB amount across all hospitals Normalized MSPB amount so that median MSPB measure equals 1.0 Source: content/uploads/2016/06/mspb_slides_npc_2016may19_finalc508.pdf 26 Interpreting the MSPB Ratio A ratio equal to the national average means that Medicare spends ABOUT THE SAME per patient for an episode of care initiated at this hospital as it does per episode of care across all inpatient hospitals nationally A ratio that is more than the national average means that Medicare spends MORE per patient for an episode of care initiated at this hospital than it does per episode of care across all inpatient hospitals nationally A ratio that is less than the national average means that Medicare spends LESS per patient for an episode of care initiated at this hospital than it does per episode of care across all inpatient hospitals nationally Source: Hospital Compare 27 9

10 28 HCC Risk Adjustment Contribution to MSPB Accounts for variation in patient case mix across hospitals by using a linear regression to estimate the relationship between risk adjustment variables and standardized episode cost Risk adjustment variables include factors such as age, severity of illness, and comorbidity interactions Each Major Diagnostic Category uses a separate linear regression model Source: content/uploads/2016/06/mspb_slides_npc_2016may19_finalc508.pdf Version 22 CMS HCC List 29 Disease Hierarchies for the CMS HCC Model 30 10

11 31 MSPB Risk Adjustment Variables MSPB Risk Adjustment Variables 32 Risk Adjustment in PSI 90 Image source:

12 34 Patient Safety Indicators (PSIs) Used to support CMS quality initiatives such as: Hospital Acquired Condition (HAC) Reduction Program Separate program from the Deficit Reduction Act: Hospital Acquired Conditions (Present on Admission [POA] program) Hospital Inpatient Quality Reporting (IQR) Program Hospital Value Based Purchasing (VBP) Program Measure of hospital quality of care for adult patients focusing on potentially avoidable complications and iatrogenic effects Source: PSI 90, Patient Safety and Adverse Events Composite Component PSIs of PSI 90 PSI 03 Pressure Ulcer Rate PSI 06 Iatrogenic Pneumothorax Rate PSI 08 In Hospital Fall with Hip Fracture PSI 09 Perioperative Hemorrhage and Hematoma Rate PSI 10 Physiologic and Metabolic Derangement Rate PSI 11 Postoperative Respiratory Failure Rate PSI 12 Perioperative Pulmonary Edema or Deep Vein Thrombosis Rate PSI 13 Postoperative Sepsis Rate PSI 14 Wound Dehiscence Rate PSI 15 Accidental Puncture and Laceration Rate 35 Risk Adjustment in PSI 90 Each PSI is risk adjusted by two overarching mechanisms: Exclusions (absolute risk adjustment) Risk factors as defined by the Agency for Healthcare Research and Quality (AHRQ) Rates are risk adjusted using (AHRQ) risk factor coefficients version 6.0 Source: ICD09/Parameter_Estimates_PSI_60.pdf 36 12

13 37 Strategies to Incorporate Risk Adjustment in PSI 90 Example: PSI 03 Pressure Ulcer Rate Selected exclusions (absolute risk adjustment) LOS < 3 days, transfer from hospital, SNF or ICF, MDC 14 Any listed diagnosis codes for hemiplegia, paraplegia, or quadriplegia, spina bifida, or anoxic brain damage POA major skin disorders Selected risk factor Identification Comorbid Conditions Hypertension with complications Chronic lung disease (COPD) Diabetes with and without complications Neurological conditions Renal failure AIDS/HIV Hypothyroidism Deficiency anemias Weight loss Presence of solid tumors without metastases Drug abuse Psychiatric conditions Source: ICD10/TechSpecs/PSI_03_Pressure_Ulcer_Rate.pdf Strategies to Incorporate Risk Adjustment in PSI 90 Example: PSI 06 Iatrogenic Pneumothorax Rate Selected exclusions (absolute risk adjustment) Pneumothorax POA Chest trauma, pleural effusion, cardiac procedure, thoracic surgery, lung/pleural biopsy, diaphragmatic repair, cardiac repair MDC 14 Selected risk factor identification Patient Related Body habitus (Obesity) Effusion size Localized fluid COPD chronic lung disease Cardiogenic pulmonary edema Acute respiratory distress syndrome Procedure Related Transthoracic needle aspiration Thoracentesis and pleural biopsy Subclavian venipuncture Abdominal cavity operations Bronchoscopy Respiratory, mechanical and positive pressure ventilation *Patient coughing during procedure Source: ICD10/TechSpecs/PSI_06_Iatrogenic_Pneumothorax_Rate.pdf 38 Strategies to Incorporate Risk Adjustment in PSI 90 Example: PSI 08 In Hospital Fall with Hip Fracture Selected exclusions (absolute risk adjustment) Self inflicted injury Principal diagnosis of hip fracture Secondary diagnosis of hip fracture present on admission (POA) Susceptible to falls Selected diagnosis codes: Seizure disorder, stroke, occlusion of arteries, coma, cardiac arrest, poisoning, trauma, delirium or other psychoses, anoxic brain injury, metastatic cancer, lymphoid and bone malignancy, disorders of musculoskeletal system and connective tissue Risk factor identification Patient Related Body habitus (Obesity) Hypertension Drug abuse Liver disease Psychoses Procedure Related COPD Diabetes w/ chronic complications Immune disorders Neurological disease Renal failure, sepsis, heart failure Source: ICD10/TechSpecs/PSI_08_In_Hospital_Fall_with_Hip_Fracture_Rate.pdf 39 13

14 40 Risk Adjustment in Hospital Compare Image source: _they_do_not_compare.jpg

15 43 Medicare.gov/Hospital Compare Risk adjustment To make comparison of hospital performance fair and level the playing field: 30 day unplanned readmission and death measures adjust for patient characteristics that may make death more likely, even if the hospital provided higher quality of care Risk adjustment calculated using the AHRQ Comorbid Conditions methodology (CC) Characteristics include Patient s age Past medical history, and other diseases or conditions (comorbidities) the patient had on admission that are known to increase the patient s risk of dying or having an unplanned readmission Medicare.gov/Hospital Compare Hospital Compare reports on the following 30 day mortality measures: Medical conditions: 30 day death rate for COPD patients 30 day death rate for heart attack patients 30 day death rate for heart failure patients 30 day death rate for pneumonia patients 30 day death rate for stroke patients Surgical procedures: 30 day death rate for coronary artery bypass graft (CABG) patients *Risk adjustment variables are the same for unplanned readmission and death rates* 44 Medicare.gov/Hospital Compare Hospital Compare reports on the following 30 day readmission measures: Medical conditions: 30 day unplanned readmission for COPD patients 30 day unplanned readmission for heart attack patients 30 day unplanned readmission for heart failure patients 30 day unplanned readmission for pneumonia patients 30 day unplanned readmission for stroke patients Surgical procedures: 30 day unplanned readmission for coronary artery bypass graft (CABG) patients 30 day unplanned readmission for hip/knee replacement Hospitalwide: 30 day unplanned readmission for any cause 45 15

16 46 Risk Adjustment in Hospital Compare Strategies to Incorporate Risk Adjustment in Hospital Compare Example: 30 Day Unplanned Readmission / Mortality for Heart Attack Selected exclusions (absolute risk adjustment) Elective CABG Staged procedures or planned readmissions Age < 65, length of stay < 2 days Transfer to another acute care facility Selected risk factor identification History of old myocardial infarction Valvular disease Diabetes with and without complications Asthma Peptic ulcer Delirium/senility/dementia Stroke Cerebrovascular disease Patient Related Source: Coronary atherosclerosis or other ischemic heart disease Metastatic cancer/leukemia/other cancers Decubitus ulcer Renal failure Deficiency anemias Drug/alcohol abuse with and without dependence Hemiplegia/paraplegia/paralysis/functional disability COPD 47 Strategies to Incorporate Risk Adjustment in Hospital Compare Example: 30 Day Unplanned Readmission / Mortality for Pneumonia Selected exclusions (absolute risk adjustment) Planned readmission Age < 65 Transfer to another acute care facility Left against medical advice Selected risk factor identification Patient Related History of CABG Diabetes with and without complications Liver disease Pneumonia Acute coronary syndrome Malnutrition Hemiplegia/paraplegia/paralysis/functional disability Dementia or senility Sepsis and septic shock Malnutrition Disorders of fluid/electrolyte/acid base Metastatic cancer/leukemia/other cancers Urinary tract infection Other endocrine/metabolic/nutritional disorders Deficiency anemias Drug or alcohol induced dependence/psychosis Source:

17 49 Strategies to Incorporate Risk Adjustment in Hospital Compare Example: 30 Day Unplanned Readmission Following TKA/THA Selected exclusions (absolute risk adjustment) Fracture of femur, hip, pelvis (implies emergent/urgent admission) Includes a partial hip arthroplasty with knee arthroplasty Revision of TKA/THA / resurfacing / removal of implanted device Mechanical complication of arthroplasty as principal diagnosis Malignant neoplasm of pelvis, sacrum, coccyx, lower limbs, bone marrow Selected risk factor identification Patient Related Skeletal deformities Morbid obesity Diabetes with and without complications Disorders or fluid/electrolyte/acid base Hemiplegia/paraplegia/paralysis/functional disability COPD Decubitus ulcer Post traumatic osteoarthritis Metastatic cancer/leukemia/other cancers Malnutrition Rheumatoid arthritis Polyneuropathy Renal failure Stroke Source: Medicare.gov/Hospital Compare Hospital Compare reports on the following Surgical Complications of Care Rates: Complication rate following elective total hip arthroplasty or total knee arthroplasty Patient Safety Indicator (PSI) composite measure 90 covered in VBP section PSI 4: Deaths Among Patients With Serious Treatable Complications After Surgery PSI 6: Iatrogenic Pneumothorax covered in VBP section PSI 12: Perioperative Pulmonary Embolism or Deep Vein Thrombosis covered in VBP section PSI 14: Postoperative Wound Dehiscence covered in VBP section PSI 15: Accidental Puncture or Laceration covered in VBP section *Risk adjustment variables are the same for unplanned readmission and death rates* 50 Strategies to Incorporate Risk Adjustment in Hospital Compare Example: Complications Following THA/TKA Selected exclusions (absolute risk adjustment) Left against medical advice (AMA); transfer from another acute care facility for the THA/TKA Femur, hip, or pelvic fractures as principal or secondary discharge diagnosis fields of the index admission Partial hip arthroplasty (PHA) procedures with a concurrent THA/TKA Revision procedures with a concurrent THA/TKA; resurfacing procedures with a concurrent THA/TKA Mechanical complication coded in the principal discharge diagnosis field Malignant neoplasm of the pelvis, sacrum, coccyx, lower limbs, or bone/bone marrow or a disseminated malignant neoplasm codedinthe principal discharge diagnosis field Removal of implanted devices/prostheses Selected risk factor identification Osteoporosis Morbid obesity Diabetes with and without complications Disorders or fluid/electrolyte/acid base Hemiplegia/paraplegia/paralysis/functional disability COPD Vertebral fractures or trauma Patient Related Source: Bone/joint/muscle infection or necrosis Metastatic cancer/leukemia/other cancers Malnutrition Rheumatoid arthritis Osteoarthritis of hip/knee Renal failure Vascular or circulatory diseases 51 17

18 52 Provider Strategies to Reduce Risk Exposure Image source: Documentation and Coding for Risk Documentation of conditions as chronic or acute on chronic While acuity is important to capture for the severity of the current condition, not documenting the chronic means from a risk standpoint, the current condition is an isolated event Chronicity of conditions means the person s health status is impacted over a greater length of time Is the acute condition an exacerbation or an aggravation of an underlying condition? 53 Documentation and Coding for Risk Examples Acute systolic/diastolic/combined heart failure Is this brand new heart failure? Is the event indicative of an undiagnosed chronic heart failure? Is the decompensation related to or caused by something else? Renal insufficiency Insufficiency is a nonspecific descriptor Does the patient have an underlying chronic kidney disease? Hepatitis B New or chronic? Manifestations? Cor pulmonale Acute or chronic? Higher risk and severity when chronic condition vs. an isolated acute condition Bronchitis Chronic, such as in COPD Seasonally related or viral (different implications for risk) 54 18

19 55 Documentation and Coding for Risk Examples (cont.) Respiratory failure Acute due to pneumonia, other lung disease, sepsis Acute on chronic (is the patient on oxygen at home?) Are other risk factors documented? Obesity Smoking status or history Sleep apnea Environmental exposure or history Hypertension Always document cause and effect or linkages Hypertensive heart disease or heart failure Hypertensive chronic kidney disease Hypertensive heart and chronic kidney disease Secondary hypertension (cause?) Documentation for Accurate Risk Adjustment Avoid the use of abbreviations Does your facility have an accepted abbreviations list? Is the abbreviation on the list? If not, write/type it out or select from a list Include all diagnoses and carry them through from admission to discharge If ruled out clearly state ruled out If resolved state resolved, then always include the diagnosis on the discharge summary Appropriate documentation of history of If currently being treated, it is a current condition Document any and all history that affects medical decision making 56 Documenting Neoplasms History of cancer does not typically influence risk adjustment Manifestation of the cancer may affect risk adjustment Organ removal or transplantation Ongoing treatment Recurrence Is the patient undergoing active treatment? If metastasis, documentation of primary site often carries risk adjustment Documenting primary site is appropriate even if primary site is no longer receiving active treatment What treatment is the patient undergoing? 57 19

20 58 Documenting Depression In ICD 10, depression is required to be coded as a single episode Consider if your patient is on medication or other treatment for depression does the patient have a singleissue depression, or is it a longer term depression? Consider other providers documentation for specificity of depression Many SSRIs are toxic to pregnant women and to breastfeeding children would a patient be on a long term toxic medication for a single episode of depression? Tools used to validate depression may be impacted by the current treatment being received if in doubt, query the provider Documenting Malnutrition Failure to thrive, cachexia, cachectic appearing are nonspecific diagnoses Are nutrition notes visible to providers? Consider ASPEN criteria (two or more present for diagnosis of malnutrition): Insufficient energy intake Weight loss Loss of subcutaneous fat Localized of generalized fluid accumulation Diminished functional status When documenting malnutrition, always include severity and type and consider the following elements: History and clinical diagnosis; clinical signs and physical examination, anthropometric data, lab indicators, dietary data/history, functional outcomes 59 Documenting Medical History History is commonly missed because providers believe that it has little or no impact on the current problem Many conditions treated and resolved should be documented because they are factual and impact risk adjustment as well as medical decision making Amputee Old MI Addiction/substance abuse/smoking Providers should document all medical history that impacts medical decision making History or current smoking status Status of device implantation History of interventional radiology procedures such as angiography, ERCP History of cancer (status or surgeries? Organ removal?) Surgical history 60 20

21 61 Documenting the Contributions of Other Providers Diagnoses from laboratory reports, radiology reports, and other non treating providers are not able to be submitted (coded) unless the treating provider also documents the diagnosis Much specificity and higher risk adjustment is lost when the surgeon or the current provider defaults to an unspecified diagnosis Common examples: Surgical clearance letters Cardiologist will include specific heart disease conditions such as type of atrial fibrillation or type of angina Surgeon only documents a fib or angina PCP clearance for surgery Wealth of medical history and specificity is not included in the surgical H&P Leveraging the EHR poor implementation of problem lists Commonly Missed Diagnoses That Increase Risk Adjustment Major depression Protein calorie malnutrition Dementia Obesity (diagnosis carries severity) Chronic obstructive pulmonary disease Manifestations of diabetes Chronic disease states DM Kidney disease Heart failure Cancer Status Amputee CABG Stents Organ transplants 62 Thank you. Questions? mdominesey@childrensnational.org 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