Regional Conference Kentucky and Indiana Chapters. August 24, 2018

Transcription

1 Regional Conference Kentucky and Indiana Chapters August 24,

2 Regional Conference Kentucky and Indiana Chapters Donald M. Blanton, MD, MS, FACEP Fellow American College of Emergency Physicians Board Certified in Emergency Medicine Board Certified in Internal Medicine AHIMA-Approved ICD-10-CM/PCS Trainer (615) (cell: voice & text) 2

3 Our Path, Today 1. MedPAR defined 2. How does data get into MedPAR? Remember: garbage in, garbage out 3. Comparative CMI assessment where do we stand? Where are the opportunities for improvement? Medicine service lines Surgery service lines Specific diagnoses (ICD-10-CM codes) 4. What do we do when we find them? 3

4 MedPAR What is in it Medicare Provider and Analysis Review (MedPAR) MEDPAR files contain information for 100% of Medicare beneficiaries using hospital inpatient services and skilled nursing facilities. Source: abstracted from UB04 Medicare billings DRGs based on ICD-10-CM codes for diagnosis and surgery, patient age, discharge destination, and sex. Relative weights of secondary diagnoses can be identified by the designated DRG DRG with MCC DRG with CC DRG with neither CC nor MCC The absence of a SDx that is a CC may be concluded if the PDx has grouped to a DRG without a CC Total charges, covered charges, Medicare reimbursement, total days, number of discharges and average total days. 4

5 Data Abstracted from Claim Forms UB 04 Used by facilities ICD-10-CM/PCS codes: - Number = complexity - Individual codes reflect severity Present on admission Length of stay Expenditures Demographics - Age - Sex - Medicaid status 5

6 MedPAR What we learn from it CMI: Medicine, Surgery, DRGs within distinct Medicare Diagnostic Categories (MDCs) Identify opportunities for improvement By looking at sub-categories MDCs, DRGs, CCs, MCCs, ICD-10-CM codes (presence or absence) Facility comparison: Health system Medicare volume Geographic area: national, state, county, city, CBSA (core-based statistical area) 6

7 Major Diagnostic Categories MDC Description 0 Pre-MDC (transplant-related) 1 Nervous System 2 Eye 3 Ear, Noes, Mouth and Throat 4 Respiratory System 5 Circulatory System 6 Digestive System 7 Hepatobiliary System and Pancreas 8 Musculoskeletal System and Connective Tissue 9 Skin, Subcutaneous Tissue and Breast 10 Endocrine, Nutritional and Metabolic System 11 Kidney and Urinary Tract 12 Male Reproductive System 13 Female Reproductive System 14 Pregnancy, Childbirth and Puerperium 15 Newborn and Other Neonates (Perinatal Period) 16 Blood and Blood Forming Organs and Immunological Disorders 17 Myeloproliferative Disorders (Poorly Differentiated Neoplasms) 18 Infectious and Parasitic Disorders 19 Mental Diseases and Disorders 20 Alcohol/Drug Use or Induced Mental Disorders 21 Injuries, Poisons and Toxic Effect of Drugs 22 Burns 23 Factors Influencing Health Status 24 Multiple Significant Trauma 25 Human Immunodeficiency Virus Infection DRGs with a respiratory PDx, not pulmonologists as a specialty. 7

8 Product of Current Documentation 8

9 CDIMD Cohorts CDIMD Cohort Traditional Medicare + Medicare Advantage Discharges Disproportionate share Resident teaching days (teaching status) 1 > 1,499 > 3% 2 > 7,999 < 3% 3 4,000 7,999 > 2% < 3% 4 4,000 7,999 < 2% < 3% 5 1,500-3,999 > 2% < 3% 6 1,500-3,999 < 2% < 3% 7 < 1,500 > 2% < 3% Hospitals are divided by CDIMD (not Medicare) into comparable sizes and teaching status, to allow more reliable comparisons. 9

10 10

11 Medical CMI Excludes vents and non-operative trauma* More than 1000 Medicare discharges. Kentucky Top 10 (of 65) Kentucky Bottom 10 (of 65) CMI 80 th 50 th 20 th * Ventilator patients are removed from analysis. CDI cannot improve those DRGs. Many trauma patients do not receive surgery. High non-operative trauma volumes can skew CMI, so they are not included. 11

12 Medical CCs Excludes vents and non-operative trauma More than 1000 Medicare discharges. Kentucky Top 10 (of 65) Kentucky Bottom 10 (of 65) CMI 80 th 50 th 20 th Facilities below the 50 th percentile for CC capture may focus CDI on those diagnoses. 12

13 Medical MCCs Excludes vents and non-operative trauma More than 1000 Medicare discharges. Kentucky Top 10 (of 65) Kentucky Bottom 10 (of 65) CMI 80 th 50 th 20 th Facilities at or below the 50 th percentile for MCC capture may focus CDI on those diagnoses. 13

14 Medical No CCs or MCCs Excludes vents and non-operative trauma More than 1000 Medicare discharges. Kentucky Top 10 (of 65) Kentucky Bottom 10 (of 65) CMI 80 th 50 th 20 th You do not want a high percentile of cases with no secondary diagnosis (SDx). 14

15 Surgery CMI Excludes traches and transplants Kentucky Top 10 (of 65) Kentucky Bottom 10 (of 65) CMI 80 th 50 th 20 th CAC Top 10 with at least 1000 procedures. Bottom 10 with at least 500 procedures. Orthopedic specialty hospitals excluded as most are elective cases, thus, few MCCs expected. 15 Cohort 7 all have < 500 procedures.

16 Surgery CCs Excludes traches and transplants Kentucky Top 10 (of 65) Kentucky Bottom 10 (of 65) CMI 80 th 50 th 20 th Top 10 with at least 1000 procedures. Bottom 10 with at least 500 procedures. Orthopedic specialty hospitals excluded as most are elective cases, thus, few MCCs expected. 16

17 Surgery MCCs Excludes traches and transplants Kentucky Top 10 (of 65) Kentucky Bottom 10 (of 65) CMI 80 th 50 th 20 th Top 10 with at least 1000 procedures. Bottom 10 with at least 500 procedures. Orthopedic specialty hospitals excluded as most are elective cases, thus, few MCCs expected. 17

18 Surgery No CCs or MCCs Excludes traches and transplants Kentucky Top 10 (of 65) Kentucky Bottom 10 (of 65) CMI 80 th 50 th 20 th You do not want a high percentile of cases with no secondary diagnosis (SDx). 18

19 19

20 Short on CCs? Not an exhaustive list Acute kidney injury Intoxication delirium Alcohol Cocaine Other stimulant (meth, K2, spice, bath salts ) Opioid Dependence Opioid Cocaine or other stimulant Sedative, hypnotic or anxiolytic Other psychoactive substance Dependence with withdrawal Alcohol Nicotine (controlled on Nicoderm) Alcoholic myopathy Acute hepatitis Acute blood loss anemia Hypertensive emergency or unspecified crisis Persistent atrial fibrillation, atrial flutter Seizures: focal, general, absence Epilepsy Malignant neoplasm, primary or secondary Hemiparesis, hemiplegia Paraparesis, paraplegia Chronic pulmonary embolus Anticoagulated for treatment or prevention of recurrence? Varicose vein with ulcer and inflammation Body mass index < 20 or > 40 Dementia with behavioral disturbance 28

21 2019 Additions to CC List B20 Human immunodeficiency virus [HIV] disease G93.40 Encephalopathy, unspecified G93.49 Other encephalopathy E88.02 Plasminogen deficiency K35.20 Acute appendicitis with generalized peritonitis, without abscess K35.30 Acute appendicitis with localized peritonitis, without perforation or gangrene K35.31 Acute appendicitis with localized peritonitis and gangrene, without perforation K Other acute appendicitis without perforation or gangrene K Other acute appendicitis without perforation, with gangrene Down-weighted from MCC Down-weighted to encourage specificity. Toxic & metabolic encephalopathy remain MCCs. The appendicitis MCC is reserved only for those with perforation or abscess. 29

22 Short on MCCs? Not an exhaustive list HF exacerbation, HTN, CKD Acute respiratory failure Heart failure exacerbation Asthma exacerbation COPD exacerbation Post-operative respiratory insufficiency Sepsis, severe sepsis Shock Encephalopathy Toxic or metabolic Functional quadriplegia Troponin elevation with demand ischemia = Type 2 MI Cerebral edema Midline shift with brain compression Acute peptic ulcer with bleeding Alcoholic gastritis with bleeding Diverticulitis with bleeding Diverticulosis with bleeding Pressure ulcer, stage 3 or 4 Acute kidney injury with tubular necrosis 30

23 2019 Additions to MCC List I63.81 Other cerebral infarction due to occlusion or stenosis of small artery I63.89 Other cerebral infarction (was MCC, code # changed from I63.8) J80 Acute respiratory distress syndrome K35.21 Acute appendicitis with generalized peritonitis, with abscess K35.32 Acute appendicitis with localized peritonitis, with perforation, without abscess K35.33 Acute appendicitis with localized peritonitis, with perforation, with abscess O86.04 Sepsis following an obstetrical procedure P35.4 Congenital Zika virus disease The appendicitis MCC is reserved only for those with perforation or abscess. 31

24 Kentucky Indiana Principal Diagnosis not Present on Admission 2017 MedPAR Data (Traditional Medicare and Medicare Advantage) Principal Diagnosis not Present on Admission (PDx not POA) Percentiles Cohort Desired = 0% 80 th 50 th 20 th Women's Hospital, Newburgh % 0.09% 0.16% 0.41% Pinnacle, Crown Point % 0.10% 0.18% 0.42% Fayette Regional, Connersville % 0.09% 0.16% 0.41% Memorial Hospital, Logansport % 0.09% 0.16% 0.41% Fleming County, Flemingsburg % 0.09% 0.16% 0.41% Bourbon Community, Paris % 0.09% 0.16% 0.41% Jewish, Shelbyville % 0.09% 0.16% 0.41% Baptist Health, Richmond % 0.03% 0.07% 0.13% The PDx has to be POA. Are these coding errors, data entry errors, computer errors? How do we establish a mechanism to catch these? Computer algorithm Discharge summary outline: Conditions: Established Chronic & POA (e.g., HTN, Diabetes, Lupus, etc.) New Acute & POA (e.g., decompensated HF, pneumonia, AMI, etc.) Hospital acquired Acute & HAC (e.g., CAUTI, DVT, etc.) 32

25 Specific ICD-10-CM Code Analysis 33

26 Asthma w/ Hypoxemia SDx w/ Acute Respiratory Failure Assumptions: Not all patients with an asthma exacerbation are hypoxic. More hospitalized as inpatients are hypoxic. Not all who are hypoxic have an acute threat to life (requirement for acute respiratory failure, ARF). MedPAR Data: Compare facilities incidence of asthma w/ hypoxia and ARF Action: Physician education: definition of acute respiratory failure Query process: Hypoxia (with option to confirm ARF) 34

27 Asthma w/ Hypoxemia SDx w/ Acute Respiratory Failure - Indiana Hospital Diagnosis & ICD-10 Language 2017 MedPAR Data (Traditional Medicare and Medicare Advantage) IN CDIMD Cohort Percentage Percentiles 80 th 50 th 20 th Eskenazi Health % 94.7% 89.2% 22.4% Indiana University Health % 94.7% 89.2% 22.4% Saint Joseph Regional % 94.1% 88.9% 80.0% IU Bloomington / Franciscan - Lafayette East % 94.1% 88.9% 80.0% Franciscan - Crown Point % 93.3% 87.0% 76.6% St Mary Medical Center % 93.3% 87.0% 76.6% 7-way Tie % 91.7% 84.4% 72.2% Major Hospital % 91.7% 84.4% 72.2% Franciscan - Dyer % 90.5% 83.3% 69.0% Hancock Regional Hospital % 90.5% 83.3% 69.0% Bloomington, Lafayette East, Major, Hancock might need to work on their definition of acute respiratory failure 35

28 Acute Respiratory Failure Hard to find a literature definition of acute respiratory failure There is, however, abundant literature about how to manage it and its underlying cause. CDIMD definition: Requirements for establishing acute respiratory failure 1. Documented hypoxia (or hypercapnea) 2. Potentially life-threatening circumstance (clinical judgment) 3. Immediate action required 36

29 Arterial %HbO 2 Saturation (SaO 2 ) Acute Hypoxemic Respiratory Failure On room air (RA) By arterial blood gas (ABG) Hypoxia = PaO 2 < 60 mmhg, SaO 2 < 88% By oxygen saturation monitor Hypoxia = SpO 2 < 90% On supplemental oxygen (P/F ratio) Divide PaO 2 (arterial) by FiO 2 60 (lowest acceptable) / 0.21 (room air) = 285 Hypoxia = quotient < 285 Translating SpO 2 to PaO 2 tables available with Respiratory assistance or monitoring - Mechanical ventilation - BiPAP (non-invasive assistance) - High-flow O 2 - Aggressive respiratory therapy - Frequent monitoring, usually ICU or ER Source: Coding Clinic, 2 nd Quarter 1990, pp 20, 21 PaO 2 (mmhg) Klabunde, R.E., Cardiovascular Physiology Concepts), 2 nd Ed., Lippincott Williams & Wilkins (2011) SpO 2 consistently < 90% If not an acute life-threatening state, requiring acute monitoring or intervention, document as hypoxemia only. 37

30 Challenges of clinical validity of coded diagnoses are only going to increase. Solve the problem at its source: Paramount Integrity 1. Literature definitions of conditions and thresholds between severities of illness 2. Capture conditions in ICD-10-CM language 3. Involve the medical staff 1. Medical staff review and agree on definitions 2. Definitions in their workflow 3. Definitions in the queries 38

31 Dependence on Supplemental Oxygen Assumption: Patients with oxygen dependency (Z99.81, not a CC) should carry the diagnosis of chronic respiratory failure with hypoxia (J96.11, a CC). Exception: temporary oxygen supplementation that is clearly situational or transient MedPAR Data: Compare facilities incidence of oxygen dependency and chronic respiratory failure. Action: Physician education: definition of chronic respiratory failure Query development: Respiratory issues (acute/chronic respiratory failure) 39

32 Indiana Diagnosis & ICD-10 Language 2017 MedPAR Data (Traditional Medicare and Medicare Advantage) Oxygen Dependence without CC (Chronic Respiratory Failure) Percentiles Cohort Incidence 20 th 50 th 80 th 16-way tie for lowest 5,6,7,8 0% % % % St Elizabeth, Lafayette East St Vincent, Kokomo King's Daughters', Madison Henry County, New Castle Indiana University, Starke Witham Health, Lebanon Women's Hospital, Newburgh Fairbanks, Indianapolis Hancock Regional, Greenfield Orthoindy Hospital, Indianapolis Physicians' Med Center, New Albany Heart Hosp Deaconess Gateway, Newburgh Kentuckiana Medical Center, Clarksville Unity Medical And Surgical, Mishawaka St Vincent, Fishers St Francis, Carmel Columbus Regional, Columbus 3 8% 0.8% 1.6% 2.8% Parkview Whitley, Columbia City 7 7% 1.7% 3.7% 7.1% Dekalb Health, Auburn 7 7% 1.7% 3.7% 7.1% Parkview Huntington, Huntington 7 7% 1.7% 3.7% 7.1% Chronic respiratory failure: 1. Confirmation of hypoxia (or hypercapnea) on room air 2. No immediate threat to life 3. Chronic and ongoing, not transient or clinically situational and temporary 40

33 Kentucky Diagnosis & ICD-10 Language 2017 MedPAR Data (Traditional Medicare and Medicare Advantage) Oxygen Dependence without CC (Chronic Respiratory Failure) 6-way tie for lowest Methodist Hospital Saint Joseph London Baptist Health La Grange Westlake Regional Hospital Middlesboro Appalachian Regional Healthcare Hospit Fleming County Hospital Percentiles Cohort Incidence 20 th 50 th 80 th 5,6,7,8 0% % % % Kentucky River 3 20% 1.7% 3.7% 7.1% Twin Lakes Regional 7 17% 1.7% 3.7% 7.1% Rockcastle Regional 7 14% 1.7% 3.7% 7.1% Harrison Memorial 7 12% 1.7% 3.7% 7.1% Chronic respiratory failure: 1. Confirmation of hypoxia on room air 2. No immediate threat to life 3. Chronic and ongoing, not transient or clinically situational and temporary 41

34 Indiana Diagnosis & ICD-10 Language 2017 MedPAR Data (Traditional Medicare and Medicare Advantage) Respiratory Infections to Simple Pneumonia Percentiles Cohort Incidence 20 th 50 th 80 th Monroe Hospital 7 65% 11% 19% 31% St Anthony, Crown Point 4 51% 20% 28% 37% St Mary Medical Center 4 50% 20% 28% 37% St Margaret, Dyer 5 44% 17% 26% 37% Indiana University, Starke 7 5% 11% 19% 31% St Francis, Mooresville 5 5% 17% 26% 37% Johnson Memorial 7 6% 11% 19% 31% Daviess Community 7 8% 17% 26% 37% CDIMD Cohort Medicare + Medicare Advantage Discharges Disproportionate share Resident teaching days (teaching status) 4 4,000 7,999 < 2% < 3% 5 1,500-3,999 > 2% < 3% 7 < 1,500 > 2% < 3% 42

35 Kentucky Diagnosis & ICD-10 Language 2017 MedPAR Data (Traditional Medicare and Medicare Advantage) Respiratory Infections to Simple Pneumonia Percentiles Cohort Incidence 20 th 50 th 80 th Middlesboro Appalachian 7 52% 11% 19% 31% Flaget Memorial 7 50% 11% 19% 31% Jewish Hospital & St Mary's 2 44% 23% 29% 38% University Of Kentucky 1 42% 20% 29% 39% Westlake Regional 7 0% 11% 19% 31% Three Rivers 7 6% 11% 19% 31% Georgetown Community 7 9% 11% 19% 31% Jennie Stuart 5 10% 17% 26% 37% CDIMD Cohort Medicare + Medicare Advantage Discharges Disproportionate share Resident teaching days (teaching status) 1 > 1,499 > 3% 2 > 7,999 < 3% 5 1,500-3,999 > 2% < 3% 6 1,500-3,999 < 2% < 3% 7 < 1,500 > 2% < 3% 43

36 Pneumonias Special Classification Note Simple pneumonias also include: Hospital acquired pneumonia (HAP) Healthcare associated pneumonia (HCAP) MS-DRG RW (ratio) Complex pneumonias (Respiratory Infections & Inflammations) 1.4 ICD 10 CM coding is based only on provider documentation of codeable conditions in the medical record, not just what a provider thinks the patient has when submitting his or her charges. If a provider enters an ICD 10 CM code into billing software but does not document the condition in the health record, a false claim has been submitted, subject to penalties. 1.0

37 MS-DRG Pneumonia Classifications Simple pneumonia and pleurisy Respiratory infections and inflammations MS-DRG 193, 194, 195 (RW 1.0) MS-DRG 177, 178, 179 (RW 1.4) Viral pneumonia (adenovirus, RSV, parainfluenza, SARS-associated coronavirus, influenza) Pneumonia due to pneumococcus, streptococcus, H. flu, mycoplasma, and chlamydia CAP, HAP, lobar, or bronchopneumonia for which an etiologic organism in the complex pneumonia category is not explicitly documented Pleurisy: adhesions lung or pleura, calcification pleura, acute, sterile, diaphragmatic, fibrous, interlobar, thickening of pleura Pneumonia is the PDx for these DRGs. Gram-negative pneumonia Salmonella, Proteus, Serratia, Klebsiella, E. coli, Pseudomonas, or GNR nonspecified Legionella Staph aureus (MSSA or MRSA) Pulmonary tuberculosis Fungus (specified) and other odd organisms Histoplasmosis, blastomycosis, candidiasis, coccidiomycosis, tularemia Aspiration pneumonia, lipoid pneumonia Empyema with/without fistula, infected bacterial pleural effusions, pleurisy w/effusions Lung abscess, gangrenous or necrotic pneumonia Mediastinitis Source: ICD-10 MS-DRG Definitions Manual Note that CAP, HCAP, HAP, or nosocomial pneumonia group to simple pneumonias, MS-DRG 193, 194,

38 Coding Rules: Uncertain Diagnoses ICD-10-CM Official Guidelines for Coding and Reporting Section II. Selection of Principal Diagnosis H. Uncertain Diagnosis If the diagnosis documented at the time of discharge is qualified as probable, suspected, likely, questionable, possible, or still to be ruled out, or other similar terms indicating uncertainty, code the condition as if it existed or was established. The bases for these guidelines are 1. The diagnostic workup, 2. Arrangements for further workup or observation, and 3. Initial therapeutic approach that correspond most closely with the established diagnosis. Note: Applies to INPATIENT admissions only. Source: ICD-10-CM Official Guidelines for Coding and Reporting Section II. Selection of Principal Diagnosis 46

39 In & Outpt Dxs Inpatient Diagnoses Translations: Medical Practice to Processing Languages Communicate the Patient s Severity of Illness MS-DRGs Medicare Severity-Diagnostic Related Groups Three tiers of severity of secondary diagnoses that add weight to the Principal Dx: Highest MCC (Major Comorbidity or Complication) Middle CC (Comorbidity or Complications Lowest Neither CC nor MCC APR-DRGs All Patients Refined-DRGs Created to better represent to the non-medicare population (pediatrics) SOI, ROM (severity of illness & risk of mortality), each represented from 1 (mild) to 4 (severe) applied to PDx and SDxs Utilized by many states Medicaid systems (including Indiana but not Kentucky) Healthgrades and US News & World Report uses for their assessment HCCs Hierarchical Condition Categories Relative weights additive from all diagnoses Used to fund Medicare Advantage, ACOs; called outpatient DRGs Used to assess clinicians for quality and cost-efficiency of care A basis for adjusting Medicare reimbursements Assess clinicians quality and cost-efficiency of care Basis for adjusting Medicare reimbursements 47

40 Complex Pneumonias Simple Pneumonias ICD-10 Code HCCs: Getting the Clinician s Attention Description HCC Code HCC RW Medicare HCC RW Mc + Medicaid HCC RW Instit. MS DRG CC/MCC J13 Pneumonia due to Streptococcus pneumoniae MCC J14 Pneumonia due to Hemophilus influenzae MCC J153 Pneumonia due to streptococcus, group B MCC J154 Pneumonia due to other streptococci MCC J181 Lobar pneumonia MCC J690 Pneumonitis due to inhalation of food and vomit (Aspiration) MCC J150 Pneumonia due to Klebsiella pneumoniae MCC J151 Pneumonia due to Pseudomonas MCC J1520 Pneumonia due to staphylococcus, unspecified MCC J15211 J15212 Pneumonia due to Methicillin susceptible Staphylococcus aureus Pneumonia due to Methicillin resistant Staphylococcus aureus MCC MCC J1529 Pneumonia due to other staphylococcus MCC J155 Pneumonia due to Escherichia coli MCC J156 Pneumonia due to other aerobic Gram-negative bacteria MCC J159 Unspecified bacterial pneumonia MCC J180 Bronchopneumonia MCC 2019 HCC RWs

41 HCC Pneumonia Possibilities ICD-10 Code Description HCC Code HCC RW Aged HCC RW Mc + Medicaid HCC RW Instit. MS DRG CC/MCC Simple pneumonia MCC Complex pneumonia MCC (Respiratory Infections & Inflammations) (3.7x) Unspecified bacterial pneumonia MCC 2019 HCC RWs 49

42 Acute GI Bleeding Assumptions: Not all GI bleeding produces acute blood loss anemia MedPAR Data: compare incidence of ABLA with GI bleed to other facilities Action Physician education of thresholds of ABLA Query development: Bleeding or abnormal blood count 50

43 Kentucky Indiana Diagnosis & ICD-10 Language 2017 MedPAR Data (Traditional Medicare and Medicare Advantage) GI Bleed without CC (Acute blood loss anemia) Percentiles Cohort Incidence 20 th 50 th 80 th Pinnacle Hospital 8 100% 11% 25% 50% Parkview Whitley 7 100% 11% 21% 43% Witham Health 7 44% 11% 21% 43% Kentuckiana Medical Center 8 40% 11% 25% 50% Fairbanks St Francis, Carmel Orthoindy Hospital Orthopaedic Hosp At Parkview No. Physicians' Medical Center Heart Hosp At Deaconess Gateway Orthopaedic Hospital of Lutheran Unity Medical And Surgical Hosp St Francis - Mooresville Daviess Community Fayette Regional Franciscan, Munster Bluffton Regional St Vincent,Carmel St Elizabeth, Crawfordsville St Margaret, Dyer 0% 7-11% 13-25% 21-50% GI Bleed without CC (Acute blood loss anemia) Women's Hospital Percentiles Cohort Incidence 20 th 50 th 80 th Harrison Memorial 7 60% 11% 22% 47% Owensboro Muhlenberg Comm. 7 60% 11% 22% 47% Clinton County Hospital 2 60% 11% 22% 47% Pineville Community 1 50% 11% 22% 47% Bourbon Community 7 0% 11% 22% 47% Logan Memorial 7 0% 11% 22% 47% Baptist, La Grange 7 0% 11% 22% 47% Westlake Regional 5 0% 7% 14% 22% St Claire Regional 7 0% 11% 22% 47%

44 Acute Blood Loss Anemia Absolute loss of RBC mass Before volume replacement and dilution e.g., acute trauma presentation, severe GI bleed Hb/Hct in the ED may be normal After volume replacement and dilution > 20% drop in hematocrit e.g., 40 to 32, 35 to 28 Fall in Hb of 2.0 g/dl from baseline Transfusion of > 2 U PRBCs Transfusion not required for the diagnosis Source: Schulman S, et al., Definition of major bleeding in clinical investigations of antihemostatic medicinal products in non-surgical patients, Journal of Thrombosis and Haemostasis, 3: , November 2004

45 Kentucky Indiana Diagnosis & ICD-10 Language 2017 MedPAR Data (Traditional Medicare and Medicare Advantage) Non-Pathologic Fracture DRG with SDx Osteoporosis Percentiles Incidence 20 th 50 th 80 th St. Francis, Mooresville 100% 11% 20% 33% Memorial, Jasper 57% 11% 18% 33% Henry County, New Castle 50% 18% 33% 50% 31-hospital tie 0% 10-18% 19-33% 27-50% Owensboro Regional, Owensboro 48% 19% 27% 27% Bourbon Community, Paris 33% 18% 33% 50% St Elizabeth, Ft Thomas 33% 11% 20% 33% 25-hospital tie 0% 10-18% 19-33% 27-50% Assumptions: Ideally, one would expect that many, if not most, fractures in patients with established osteoporosis to be labeled pathologic. Observation: Fewer fractures are labeled pathologic than expected in the setting of osteoporosis as SDx. Action: Clinician education Develop osteoporosis fracture query 53

46 Calculating Fiscal Opportunity From Comparative MedPAR Data 54

47 Kentucky CDIMD cohort 01 Medicine CMI (excluding ventilator and non-operative trauma DRGs*) Base Rate Volume Fiscal Opportunity Percentiles 20 th 50 th 80 th M-CMI* University of Kentucky Hospital $7,733 8, University of Louisville Hospital $8,517 3, Indiana CDIMD cohort MedPAR Data (Traditional Medicare and Medicare Advantage) Base Rate Volume Percentiles 20 th 50 th 80 th M-CMI* Eskenazi Health $8,720 3, Indiana University Health $8,093 10, Large Teaching Hospitals CDIMD Traditional Medicare + Medicare Resident teaching days Disproportionate share Cohort Advantage Discharges (teaching status) 01 > 1,499 > 3% 55

48 Indiana CDIMD cohort 02 Medicine CMI (excluding ventilator and non-operative trauma DRGs*) 2017 MedPAR Data (Traditional Medicare and Medicare Advantage) Base Rate Volume Percentiles 20 th 50 th th M-CMI* St Francis, Indianapolis $6,294 7, St Vincent, Indianapolis $6,799 8, Indiana University, Ball Memorial $6,119 6, $348,000 Floyd Memorial, New Albany $6,803 5, $327,000 Community Hospital, Munster $6,111 8, $677,000 Lutheran, Fort Wayne $6,250 6, $955,000 Deaconess, Newburgh $6,129 11, $1,843,000 Parkview Regional, Fort Wayne $6,191 10, $1,927,000 Opportunity when CMI rises to 50 th percentile $2,641,000 $1,964,000 $3,145,000 $2,909,000 $5,307,000 $5,238,000 Opportunity when CMI rises to 80 th percentile Large Non-Teaching Hospitals CDIMD Traditional Medicare + Medicare Resident teaching days Disproportionate share Cohort Advantage Discharges (teaching status) 02 > 7,999 < 3% 56

49 Calculating Opportunity Hospital CMI (excluding ventilator and non-operative trauma DRGs) Deaconess CMI at 50 th percentile for the cohort Establish the difference between = Multiply by the volume 11,264 Multiply by the base rate $6, x 11,264 x $6,129 = $1,843,000 57

50 Indiana CDIMD cohort 03 Medicine CMI (excluding ventilator and non-operative trauma DRGs*) Base Rate Volume Percentiles 20 th 50 th 80 th M-CMI* IU Health, Bloomington $6,506 3, St Elizabeth - Lafayette East $6,401 3, IU Health, Arnett $6,308 3, St. Mary s, Evansville $6,352 5, Reid Health $6,436 5, $14,000 Clark Memorial Hospital $6,390 3, $293,000 Memorial of South Bend $6,799 4, $529,000 Elkhart General Hospital $6,345 3, $724,000 Saint Joseph Regional Med Ctr $6,673 4, $1,159,000 Porter Regional $6,267 4, $81,000 $1,387,000 Columbus Regional Hospital $6,436 3, $336,000 $1,409,000 Union Hospital, Terre Haute $6,678 5, $1,096,000 $2,478,000 Community Hospital, North $6,391 4, $1,145,000 $2,928,000 Community Hospital, East $7,056 4, $1,450,000 $2,998,000 Community Hospital, South $6,298 3, $962,000 $1,947,000 Methodist, Gary $6,587 6, $1,810,000 $3,933,000 $5,845,000 CDIMD Traditional Medicare + Medicare Resident teaching days Disproportionate share Cohort Advantage Discharges (teaching status) 03 4,000 7,999 > 2% < 3% 58

51 Indiana CDIMD cohort 05 Medicine CMI (excluding ventilator and non-operative trauma DRGs*) 2017 MedPAR Data (Traditional Medicare and Medicare Advantage) Base Rate Percentiles Volume 20 th 50 th 80 th M-CMI* Community Howard, Kokomo $6,284 1, $492,000 Major Hospital, Shelbyville $6,889 1, $481,000 Comm., Anderson & Madison Co $6,360 2, $101,000 $1,045,000 King's Daughters, Madison $6,316 1, $198,000 $743,000 St Joseph, Fort Wayne $6,937 1, $372,000 $945,000 Kosciusko Community, Warsaw $6,216 1, $284,000 $710,000 Terre Haute Regional $6,258 2, $709,000 $1,589,000 St Francis, Mooresville $6, $200,000 $426,000 Marion General Hospital $6,472 2, $919,000 $1,767,000 Dearborn County, Lawrenceburg $6,255 1, $292,000 $982,000 $1,578,000 CDIMD Traditional Medicare + Medicare Resident teaching days Disproportionate share Cohort Advantage Discharges (teaching status) 05 1,500-3,999 > 2% < 3% 61

52 Medicine CMI (excluding ventilator and non-operative trauma DRGs*) Indiana CDIMD cohort MedPAR Data (Traditional Medicare and Medicare Advantage) Base Rate Volume Percentiles 20 th 50 th 80 th M-CMI* Daviess Community Hospital 7,244 1, $394,000 Witham Health Services 7,111 1, $455,000 Henry County Memorial Hospital 7, $383,000 Bluffton Regional Medical Center 7, $407,000 Parkview Noble Hospital 7, ,000 $695,000 Parkview Huntington Hospital 7, ,000 $734,000 Parkview Whitley Hospital 7, ,000 $826,000 Dekalb Health 6, ,000 $1,167,000 Women's Hospital The 6, ,000 37,000 $44,000 CDIMD Traditional Medicare + Medicare Resident teaching days Disproportionate share Cohort Advantage Discharges (teaching status) 07 < 1,500 > 2% < 3% 64

53 Kentucky CDIMD cohort 02 Medicine CMI (excluding ventilator and non-operative trauma DRGs*) 2017 MedPAR Data (Traditional Medicare and Medicare Advantage) Base Percentiles Volume Rate 20 th 50 th 80 th M-CMI* Baptist, Lexington $6,363 5, Baptist, Louisville $6,158 9, Jewish & St Mary s, Louisville $6,834 10, $272,000 Pikeville Medical Center $6,640 5, $648,000 Owensboro Regional $6,380 5, $ 1,015,000 Medl Center at Bowling Green $6,472 5, $1,156,000 $ 2,967,000 King's Daughters, Ashland $6,416 5, $1,593,000 $ 3,417,000 Norton/Kosair Ch, Louisville $6,918 18, $5,421,000 $11,500,000 St Elizabeth North, Covington $6,558 8, $223,000 $2,800,000 $ 5,421,000 Large Non-Teaching Hospitals CDIMD Traditional Medicare + Medicare Resident teaching days Disproportionate share Cohort Advantage Discharges (teaching status) 02 > 7,999 < 3% 66

54 Kentucky CDIMD cohort 03 Medicine CMI (excluding ventilator and non-operative trauma DRGs*) 2017 MedPAR Data (Traditional Medicare and Medicare Advantage) Base Rate Volume Percentiles 20 th 50 th 80 th M-CMI* Saint Joseph, Lexington $6,303 4, Hardin Mem, Elizabethtown $6,436 5, $1,064,000 Baptist Health, Madisonville $6,702 3, $875,000 Lake Cumberland, Somerset $6,674 4, $1,151,000 Hazard ARH Regional $6,576 4, $1,256,000 Lourdes Hospital, Paducah $6,219 4, $460,000 $1,731,000 Baptist Health, Paducah $6,280 3, $774,000 $1,873,000 St Elizabeth, Florence $6,399 4, $237,000 $1,661,000 $2,943,000 CDIMD Traditional Medicare + Medicare Resident teaching days Disproportionate share Cohort Advantage Discharges (teaching status) 03 4,000 7,999 > 2% < 3% 67

55 Kentucky CDIMD cohort 05 Medicine CMI (excluding ventilator and non-operative trauma DRGs*) 2017 MedPAR Data (Traditional Medicare and Medicare Advantage) Base Rate Volume Percentiles 20 th 50 th 80 th M-CMI* Methodist Hospital, Henderson $6,674 1, $582,000 St Elizabeth, Ft Thomas $6,371 3, $1,210,000 $2,351,000 Whitesburg ARH Hospital $6,366 1, $542,000 $1,051,000 Jackson Purchase, Mayfield $6,213 1, $99,000 $873,000 $1,543,000 Highlands Regional, Prestonsburg $6,523 1, $389,000 $1,108,000 $1,729,000 Harlan ARH Hospital $6,561 1, $815,000 $1,562,000 $2,208,000 Murray-Calloway County Hospital $6,296 1, $739,000 $1,389,000 $1,950,000 Jennie Stuart, Hopkinsville $6,286 1, $1,023,000 $1,774,000 $2,423,000 Kentucky CDIMD cohort 06 M-CMI* Greenview Regional, Bowling Green $6,071 1, $170k $817k $1,630k CDIMD Cohort Traditional Medicare + Medicare Advantage Discharges Disproportionate share 05 1,500-3,999 > 2% < 3% 06 1,500-3,999 < 2% < 3% Resident teaching days (teaching status) 69

56 Medicine CMI (excluding ventilator and non-operative trauma DRGs*) Kentucky CDIMD cohort MedPAR Data (Traditional Medicare and Medicare Advantage) Base Rate Volume Percentiles 20 th 50 th 80 th M-CMI* Bourbon Community, Paris $6, $256,000 $537,000 Pineville Community Hospital $6, $479,000 $936,000 Crittenden, Marion $7, $14,000 $362,000 $645,000 Rockcastle, Mount Vernon $6, $202,000 $568,000 $866,000 Clinton County, Albany $7, $220,000 $579,000 $870,000 Harrison Memorial, Cynthiana $6, $270,000 $689,000 $1,029,000 Monroe County, Tompkinsville $7, $502,000 $1,078,000 $1,547,000 CDIMD Traditional Medicare + Medicare Resident teaching days Disproportionate share Cohort Advantage Discharges (teaching status) 07 < 1,500 > 2% < 3% 72

57 MDC 4 DRGs PE Pneumonias COPD Bronchitis & Asthma Respiratory Neoplasms Pleural Effusion Pulm Edema & ARF Resp Dx & Ventilators Interstitial Lung Dis Pneumothorax Resp Signs & Sx Major Chest Trauma Mj Chest Procedures Jennie Stuart Pulmonary DRGs (MDC 4) 2017 MedPAR Data (Traditional Medicare and Medicare Advantage) KY cohort 05 Medicine CMI Percentiles MDC 4-CMI Vol 20 th 50 th 80 th ($338,222) ($692,435) Medicine MCC% Percentiles MCCs 20th 50th 80th 35% % 53% 62% Medicine CC% Percentiles CCs 20th 50th 80th 39% % 31% 37% Medicine No CC or MCC% Percentiles No CC/MCC 20th 50th 80th 26% % 15% 21% 50 th p opportunity x 636 (Vol) x $6,286 (base) $338, th p opportunity x 636 (Vol) x $6,286 (base) $692,435 73

58 MDC 4 DRGs PE Pneumonias COPD Bronchitis & Asthma Respiratory Neoplasms Pleural Effusion Pulm Edema & ARF Resp Dx & Ventilators Interstitial Lung Dis Pneumothorax Resp Signs & Sx Major Chest Trauma Mj Chest Procedures St. Joseph, East Pulmonary DRGs (MDC 4) 2017 MedPAR Data (Traditional Medicare and Medicare Advantage) KY cohort 05 Medicine CMI Percentiles MDC 4-CMI Vol 20th 50th 80th Medicine MCC% Percentiles MCCs 20th 50th 80th 73% % 53% 62% Medicine CC% Percentiles CCs 20th 50th 80th 16% 24 26% 31% 37% Medicine No CC or MCC% Percentiles No CC/MCC 20th 50th 80th 10% 15 11% 15% 21% 74

59 St. Joseph, East General Surgery 2016 MedPAR Data (Traditional Medicare and Medicare Advantage) KY cohort 05 General Surgery CMI Percentiles CMI Vol 20th 50th 80th , ($79,000) ($1,550,000) ($3,732,000) General Surgery MCC% Percentiles MCCs 20th 50th 80th 14% % 24% 32% General Surgery CC% Percentiles CCs 20th 50th 80th 14% % 29% 35% General Surgery No CC or MCC% Percentiles No CC/MCC 20th 50th 80th 71% % 45% 55% 75

60 MedPAR data has told us a lot. 76

61 The Problem with Documentation Doctors: Doctors don t document well. Few English majors We don t edit our work. We use terms without consideration of their literature definition. We take care of conditions without noting their existence. We will treat the heart failure, but not recognize that the patient also had acute respiratory failure. We take care of conditions without using the term that adds relative weight. We will treat oxygen dependence, but not call it chronic respiratory failure. 77

62 Opportunity in Surgical CMI A Solution: Capture secondary diagnoses in the pre-anesthesia assessment interview Structured interview Document responses in ICD-10-CM language Match to relative weights of CCs, MCCs where appropriate and accurate Match to relative weights of HCCs, where appropriate and accurate Present to anesthesiologist for review and co-sign Signing by licensed provider with face-to-face contact with the patient makes them available to be coded. 79

63 Hospital Process MD Office Pre-Operative Assessment Clinic Pre-Admit Evaluation and Documentation Workflow The preadmission process collates clinical information from surgeon & PCP. Templated RN interview produces secondary diagnoses in language that are codeable in ICD-10-CM. Information is reviewed and co-signed by a nurse practitioner or anesthesiologist making diagnoses eligible for coding. Surgeon s Office Visit Decision to Operate Scripted interview places responses in ICD-10-CM language. Anesthesiologist s cosign makes diagnoses available for coding. Establish Operation Day and Time Data Collection Process Completion of Preoperative Assessment Tool Needs Immediate Anesthesia Review? Anesthesia Review within 24 hours of surgery Final Anesthesia Assessment & Signature Surgeon s Records Patient Interview Primary Care or Other Physician s Records Preoperative Testing Results Review by Anesthesia with Additional Ordering of Tests or Consultations Completion of Initial Anesthesia Assessment Form 80

64 Problem: Inaccurate Documented Language Solution: Physician Buy-In on Agreed Definitions Accumulate from the professional medical literature, definitions of clinical conditions and thresholds between severities of illness Acute kidney injury Kidney Disease: Improving Global Outcomes (KDIGO). Acute Kidney Injury Work Group. KDIGO clinical practice guidelines for acute kidney injury. Kidney Int Suppl 2012; 2:1 Troponin elevation, demand ischemia, and type 2 MI Third Universal Definition of Myocardial Infarction, Circulation, August 24, 2012 Sepsis, severe sepsis, septic shock Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3), JAMA, February 22, 2016 Many others Present to Physician Advisor, Chief Medical Officer, Chief of Staff, Department Head, Hospitalists, or individual physicians Discuss among clinicians Establish Medical Staff agreed facility definitions Helpful to clinicians, CDSs, and coders Useful for teaching 81

65 Rules of Three Documenting all conditions 1. Three mentions (to establish validity) 1. At first diagnosis: emergency physician note, H&P, consultation 2. Progress note 3. Discharge summary 2. Three parts of speech 1. Noun (condition) 2. Adjective (acute/chronic; improved, stable, worse, resolved, etc.) and why they cannot go home today 3. Verb (what you are going to do) 3. Once on the problem list, always on the problem list 1. Preserve them for the discharge summary 2. Cite as new, a condition that begins after the inpatient order, or present on admission (POA) obvious, if on EP note/h&p 3. Improved, deteriorated, stable, chronic, ruled out, resolved Many conditions resolve with intervention. Don t forget them. 89

66 M U S I C Conditions, Details, & Interdependencies MUSIC Manifestation - Presenting signs, symptoms, syndromes Fatigue, polyuria Underlying Cause Diabetes Severity or Specificity Diabetes with hyperglycemia Instigating or precipitating causes Short-term steroid due to treatment of COPD exacerbation Consequences or Complications diabetic gastroparesis, diabetic retinopathy Caused by, Due to, Resulting in When given a diagnosis, place it one of these categories and then look for the other four, linking them with terms such as caused by, due to, or resulting in whenever possible. 90

67 Communicating the Medical Necessity for Inpatient Status Factors included in the decision to hospitalize as an inpatient Primary Diagnosis (i.e., why they cannot go home) Severity of signs and symptoms, stability ill, toxic, distress, high fever, uncertain early course, insignificant response to ED intervention, failure of outpatient management Complexity of secondary diagnoses Concern for stress of the acute infection given ASCVD and prior MI Concern for decompensation of DM given requirement of steroids for COPD Medical needs for testing, treatment that cannot be accomplished in the office, the ED, or in observation status Risk of adverse events: Medical predictability (judgment) of something adverse happening to the patient Expectation that the hospitalization will cross 2 midnights (Traditional Medicare only) Inpatient hospitalization with the expectation of crossing 2-midnights. Federal Register/Vol. 80, No. 219/Friday, November 13, 2015/Rules and Regulations, PART 412 PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES, p Every patient, to a reviewer, looks the same: a white piece of paper with ink on it. Paint the picture of the patient s severity and complexity so it will be obvious to the auditor. 91

68 Communicating Medical Necessity Applicable to Consults, Office Notes Primary Diagnosis (i.e., nature of the presenting problem) Concern for lack of definitive diagnosis; risk of differential diagnoses Severity of signs and symptoms, stability ill appearing, distress, high fever, uncertain early course, failure of initial management Complexity of secondary diagnoses Concern for stress of the acute infection given ASCVD and prior MI Concern for decompensation of DM given requirement of steroids for COPD Concern for effect of antibiotic on Coumadin anticoagulation Medical needs for testing, treatment Risk of adverse events: Medical predictability (judgment) of something adverse happening to the patient Rule of 3: Noun-Adjective-Verb / Condition-Status-Plan / e.g., Diabetes type 2, controlled, continue metformin Modified from: Federal Register/Vol. 80, No. 219/Friday, November 13, 2015/Rules and Regulations, PART 412 PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES, p Every patient, to a reviewer, looks the same: a white piece of paper with ink on it. Paint the picture of the patient s severity and complexity so it will be obvious to the reader. 92

69 Decision-Making, Planning Stakeholders Director of HIM Director of CDI Chief Financial Officer Physician Advisor / Chief Medical Officer / Heads of Departments Others as identified 93

70 94

71 95

72 96

73 Regional Conference Kentucky and Indiana Chapters August 24,