Learning Objectives. Novant Health. Novant Health Ambulatory CDI: How We ve Grown!

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1 1 Novant Health Ambulatory CDI: How We ve Grown! Yvonne Whitley, RN, BSN, CPC, CRC, CDEO Supervisor, Novant Health Medical Group Clinical Documentation Improvement Novant Health Winston Salem, NC Learning Objectives At the completion of this educational activity, the learner will be able to: Define what is a Risk Adjustment Model Describe the components of RAF (Risk Adjustment Factor) Recall the PGP 1.0 Demonstration Project Explain the improvements and advances made with Novant Health Ambulatory Clinical Documentation Improvement List and describe Novant Health CDI tools 2 Novant Health Making healthcare remarkable Not for profit, integrated health system that spans communities in the Carolinas, Virginia and Georgia Over 24,000 employees and physician partners 463 physician locations and 15 medical centers Nationally recognized for quality and safety measures HIMSS Stage 7 Ambulatory Award Epic Professional Billing MPV Award Over 675,000 MyNovant users 3 1

2 4 Risk Adjustment Model Model used by CMS and other Medicare Advantage (MA) payers taking known variables to predict future resources required. What does this mean? This can impact your reimbursement from payers if you are being measured by value (quality/cost). For Medicare, it will show in shared savings and/or fee schedule increases depending on the contract. Risk Adjustment Model Risk Adjustment Factor (RAF) HCC (Hierarchical Condition Category) diagnoses from all claims submitted in a calendar year Demographics age/gender/race/insurance status/others (points calculated by socioeconomic standings) Must be face to face encounter with an eligible provider Must address each HCC diagnosis once per calendar year Higher the RAF score = higher complexity of care required for the patient = higher predicted costs for care of the patient Example of some models: Medicaid (Chronic Illness and Disability Payment System [CDPS]) Medicare (CMS Hierarchical Condition Category [CMS HCC]) Inpatient (Diagnosis Related Group [DRG]) 5 Impact of RAF on Financials Moving from a payment model of fee for service to pay for performance (quality at lower cost) Current year claims with diagnoses affect reimbursement allocations 2 years later Chronic conditions require increasing costs; unspecified diagnoses = underpayment and limited resources available DRG coding different than ambulatory (for Part B, all diagnoses are included that affect medical decisionmaking) 6 2

3 7 HCC (Hierarchical Condition Category) Diagnoses filtered by groups, then into condition categories Usually chronic, permanent condition that is considered costly Trumping Disease interactions Can be cumulative HCC Categories Disease Category Description Coefficient HCC 8 HCC 9 HCC 10 HCC 11 HCC 12 HCC 17 HCC 18 HCC 19 Metastatic Cancer and Acute Leukemia Lung and Other Severe Cancers Lymphoma and Other Cancers Colorectal, Bladder, and Other Cancers Breast, Prostate, and Other Cancers and Tumors Diabetes with Acute Complications Diabetes with Chronic Complications Diabetes without Complications HCC Disease Interactions Disease Category Description Coefficient CANCER/IMMUNE Cancer/Immune Disorders CHF/COPD CHF/COPD CHF/RENAL CHF/Renal Disease COPD/CARD/RESP FAILURE COPD/Cardiorespiratory Failure DIABETES/CHF Diabetes/CHF SEPSIS/CARD/RESP FAILURE Sepsis/Cardiorespiratory Failure

4 10 HCC Diagnoses Comparison If this HCC Description label Then these are cancelled found HCC 8 Metastatic Cancer and Acute Leukemia 9, 10, 11, 12 HCC 9 Lung and Other Severe Cancers 10, 11, 12 HCC 10 Lymphoma and Other Cancers 11, 12 HCC 11 Colorectal, Bladder, and Other Cancers 12 HCC 12 Breast, Prostate, and Other Cancers and Tumors HCC 17 Diabetes with Acute Complications 18, 19 HCC 18 Diabetes with Chronic Complications 19 HCC 19 Diabetes without Complications HCC 137 Chronic Kidney Disease Severe (Stage 4) _ The Impetus for Ambulatory CDI: The PGP 1.0 Demonstration Project PGP = Physician Group Practice (included 10 health systems across the country) CMS demonstration project on FFS patients ACO like Pilot Quality & integration will drive down total cost of care Shared savings incentive No downside risk 11 PGP Demonstration Project Results NH PGP started and ended with the highest quality scores possible NH PGP performed better than all other 9 PGP groups on per capita expenses Potential: $25 million and national recognition Received: $0 and little recognition How did that happen? 12 4

5 13 PGP Demonstration Project NH PGP had the lowest risk score (RAF) Below average rate/10,000 on 98% of all HCCs Conclusion: Since the NH patient population wasn t that sick, the high quality care provided should have been at an even lower actual cost = no shared savings How could we improve? Ambulatory CDI in the Beginning Created Sept 2013 Initially 3 RNs targeting the PCPs in 2 of 4 markets (Winston Salem and Charlotte markets only) Targeted providers based on reports run from claims on frequency of usage of (ICD 9 code ) diabetes Type 2 without complications vs. all other diabetes with complication codes Focused initially on 4 low hanging HCC fruit : Diabetes, morbid obesity, depression, and dependence 14 Ambulatory CDI in the Beginning Developed paper query form Met face to face with each provider to teach the why queries per provider Depending on number of providers, CDSs would be available on site every day (sometimes up to a month) 15 5

6 16 Ambulatory CDI Today Team of 11 RN CDSs educating PCPs, cardiology, hematology/oncology, and neurology/behavioral health 2 RN CDS analysts focused on payer reports to close patient care gaps Created policy/procedure and productivity metrics for team member accountability and efficiency In process of completing CPC, CRC, and CDEO certification Ambulatory CDI Today Query on specificity for ALL diagnoses to each provider every 8 10 weeks 3 types of scenarios: 1. Documentation present to support multiple diagnoses, but very few diagnoses listed 2. Many diagnoses listed with no supporting documentation 3. Frequent use of unspecified diagnoses Developing streamlined electronic query and reporting tools 17 Ambulatory CDI Today Extract data from thousands of charts for Physician Quality Reporting System Built relationships and now collaborate with multiple diverse teams: Coding and Coding Education Corporate Compliance Clinical Services Dimensions (EPIC) Acute CDI Payers Contributed to increased RAF score potentially opening the door for increased shared savings Through payer data analysis, identified coding issues with claims: partnered with coding to identify solutions 18 6

7 19 CDI Tools Scripting for CDSs regarding the why for increased specificity with diagnoses and documentation keeping the education consistent Reference guides for providers on tips regarding specific diagnoses Queries to providers (usually prospective) CDS productivity tracking spreadsheet Favorites diagnosis list within EPIC HCC refresh needed EPIC tool CDI Tools: Snapshot Sample Query Clinician: Dr. No Name MRN: XXXXXXX Patient Name / DOB: Doe, John A 1/1/50 Next Visit Date: 1/1/ Current Dx: DM Type 2 without complications Clinical Indicators: GFR results consistently 40s 50s over the last 2 years. Med list includes Lantus 18 units subcutaneous bid. Based on your independent clinical judgment, can the current diagnosis be further specified? Diabetes Clarification Agree Disagree Renal manifestation (must include e.g., CKD with specified stage, albuminuria, nephropathy) Other specified manifestations (e.g., diabetic dyslipidemia, ED, skin ulcers/cellulitis) Long term use of insulin Other diagnosis (please specify) Unable to determine 20 CDI Tools: Snapshot HCC Refresh Needed 21 7

8 22 CDI Tools: Snapshot HCC Refresh Needed CDI Tools: Snapshot Reference Guide **DM with hyperglycemia to be used in addition to any of the diabetes with manifestation codes below to indicate uncontrolled diabetes. Documentation must include cause and effect ( due to ).** Specify and document if DM Type 1 or Type 2 as well as for each below: DM with kidney complications: If nephropathy or CKD and stage (if CKD, must specify CKD stage) DM with ophthalmic complications: Mild/moderate/severe proliferative/ nonproliferative retinopathy, with/without macular edema, diabetic cataract or diabetic glaucoma DM with neurological complications: Type of neuropathy (mono /polyautonomic neuropathy or amyotrophy) DM with circulatory complications: Peripheral angiopathy with/without gangrene DM with other specified complications: Neuropathic arthropathy (Charcot s joints) or other diabetic arthropathy DM with skin complications: Diabetic dermatitis, foot or other ulcer (requires additional code for site of ulcer) 23 Query Opportunity Patient comes in for FU of DM and HTN. Records reveal he was in the ED 2 weeks prior with SOB and 10 lb weight gain. AMI was ruled out and he was placed on diuretic. Discharged next day feeling much better with a 8 lb diuresis. Patient states he feels much better but still has mild leg pain and dyspnea on exertion over the last 6 months. Exam revealed: Lungs, clear, BP 128/75, pulse 76 reg DM foot exam: Normal other than diminished pulses bilateral and trace ankle edema Review of recent echo shows LVH with normal EF and pulm HTN Review of lab shows GFRs less than 50 over the last 6 months Assessment: DM without complications Essential HTN, HTN goal unspecified Pain of lower extremity, laterality unspecified 24 8

9 25 Query Opportunity Clinical documentation to support query: DM foot exam: Normal other than diminished pulses bilateral and trace ankle edema DM with PAD? Review of recent echo shows LVH with normal EF and pulm HTN and still has mild leg pain and dyspnea on exertion over the last 6 months HTN heart disease with HF diastolic HF and pulmonary HTN? Review of lab shows GFRs less than 50 over the last 6 months CKD stage 3? HCC Diagnoses Comparison Actual diagnosis HCC value Potential diagnosis (with documentation to support) HCC value DM DM with PAD HTN 0 HTN heart disease with HF and CKD stage Leg pain 0 Diastolic HF Pulm HTN Total What We ve Learned for Provider Engagement Face to face meetings Reinforce the why MACRA/MIPS/RAF impact on reimbursement Teaching clinical staff, including practice managers Senior leadership support Persistence Sense of humor Flexibility Brainstorming for fresh ideas to engage providers Building respectful relationships 27 9

10 28 Thank you. Questions? 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. 10