Mortality Risk Adjustment and HCCs: Is This the New 'Sweet Spot' for Physician Buy In?

Transcription

1 Mortality Risk Adjustment and HCCs: Is This the New 'Sweet Spot' for Physician Buy In? Kyra Brown, RHIA, CCS, CCDS Clinical Documentation Manager/Educator Erlanger Chattanooga, TN 1

2 Learning Objectives At the completion of this educational activity, the learner will be able to: Describe why a hospital can have the majority of their expired patients in SOI 4 & ROM 4 and have a one star rating on mortality quality measures Explain how physician office documentation and coding affect a hospital s risk adjustment mortality rates Identify diagnoses that have a positive effect on risk adjustment measures for AMI, COPD, stroke, CHF, and pneumonia Discuss factors that impede risk adjustment diagnosis documentation and/or coding 2

3 30 Day Risk Standardized Mortality Measure Medicare patients; age 65+. With Part A and B for 12 months. Patients with a principal diagnosis of one of the following, that expired within 30 days of admission: Acute myocardial infarction Chronic obstructive pulmonary disease (ARF) Heart failure Pneumonia (sepsis) Ischemic stroke Exclusions: Patients enrolled in hospice any time in past 12 months and/or those discharged AMA. All deaths are considered an outcome, regardless of cause. Example: AMI patient discharged and involved in car wreck on the way home from the hospital. 3

4 Why Were Erlanger s Star Ratings So Low? Lessons Learned Initially I was extremely perplexed at these findings since most of our expired patients are a SOI 4/ROM 4 Then I performed extensive research on risk adjusted mortality And discovered that the diagnoses used for risk adjustment are only those present on admission Our documentation was lacking Coding of some of the conditions was lacking as well The focus was on DRG (CC/MCC) and SOI/ROM Some of the risk adjustment diagnoses have no value to SOI/ROM and are not CCs or MCCs When it came down to it, we did not know what we did not know! 4

5 Sweet Spot 1. The place on a bat, club, or paddle where it is most effective to hit a ball* 2. An area or range that is most effective or beneficial: an engine s sweet spot of RPMs for maximum fuel efficiency* Key represents sweet spot *American Heritage Dictionary of the English Language, Fifth Edition. Copyright by Houghton Mifflin Harcourt Publishing Company. Published by Houghton Mifflin Publishing Company 5

6 The Sweet Spot Could the link between mortality risk adjustment and HCCs be the most effective or beneficial means of obtaining physician buy in? 6

7 Hospital Mortality Risk Adjustment Variables For each patient, risk adjustment variables are obtained from inpatient, outpatient, and physician Medicare administrative claims data extending 12 months prior to, and including, the index Physician Office HCCs Are Assigned Based On: Previous 12 months coded data Diagnosis reported and coded in: * (p3) Inpatient hospitals Outpatient hospitals Physician practices admission**(p. 12) **2017 Condition Specific Measures Updates and Specifications Report Hospital Level 30 day Risk Standardized Mortality Measures *The role of HCCs in a value based payment system; October 2017 Healthcare Financial Management 7

8 Mortality Risk Adjustment Variables Index admission is the hospitalization to which the mortality outcome is attributed* (p. 9) The measure adjusts for case mix differences among hospitals based on the clinical status of the patient at the time of the index admission*(p. 9) Accordingly, only comorbidities that convey information about the patient at that time or in the 12 months prior, and not complications that arise during the course of the hospitalization, are included in risk adjustment*(p. 9) *2017 Condition Specific Measures Updates and Specifications Report Hospital Level 30 day Risk Standardized Mortality Measures 8

9 HCCs Each HCC is weighted using a risk adjustment factor (RAF) that is similar in theory to DRG relative weights. The higher the RAF score, the higher the assumed risk and payment. HCCs ultimately provide a snapshot into patient severity. This snapshot gives insurers valuable information that they can use to: Assess outcomes Predict costs Gauge overall hospital performance The role of HCCs in a value based payment system; October 2017 Healthcare Financial Management 9

10 What s in It for the Hospital? As more physician practices are acquired by hospitals and physicians become employees, reduced reimbursement for services that do not demonstrate quality services based on SOI & ROM will adversely impact the facility s bottom line. Documentation of the HCCs will maximize the revenue of hospital based practices. Fernandez, Valarie. Ins and Outs of HCCs. Journal of AHIMA 88, no. 6 (June 2017):

11 What s in It for the Physician? Barrier: The physician mindset that only one diagnosis is needed for billing. You also have a very pervasive mindset out there in the smaller physician practices that still believe that Medicare still only looks at a single diagnosis code, and so there s really no value or point in reporting all those additional secondary conditions, because your claim is going to be processed and paid on one single diagnosis code. Butler, Mary. Money Troubles: Changing Reimbursement Models Shake Up Physician and Outpatient Healthcare Industry. Journal of AHIMA 88, no. 9 (September 2017):

12 Top 10 Medicare Risk Adjustment Coding Errors* Health record does not have a legible signature with credentials Electronic health record was not authenticated & electronically signed Highest degree of specificity was not assigned to dx A discrepancy exists between billed dx and actual description of the condition noted in documentation Documentation does not indicate a condition as being monitored, evaluated, assessed, or treated Cancer status is unclear and treatment is not documented Chronic conditions such as hepatitis are not documented as chronic Lack of specificity is an issue, such as unspecified arrhythmia versus a specific type of arrhythmia Chronic conditions and status codes are not documented on an annual basis Required linking language, causal relationship, or manifestation codes are missing *Fernandez, Valerie. Ins and Outs of HCCs. Journal of AHIMA 88, no. 6 (June 2017): **Bolded items are applicable to both inpatient and physician office. 12

13 What s in It for the Physician? Accurate reimbursement is dependent on complete physician documentation 13

14 HCC Example: 76 Year Old Female, Lives at Home 2015: Diagnoses HCC** Relative Factor Diabetes with retinopathy Morbid obesity Rheumatoid factor AAA without rupture COPD monthly payment: $2, : Diagnoses HCC Relative Factor Diabetes without complications Obesity No HCC (unless morbid) COPD monthly payment: $ Annual decrease of $20, *The role of HCCs in a value based payment system; October 2017 Healthcare Financial Management **See end of presentation for HCCs link 14

15 Mortality Risk Adjustment: Diagnoses That Have a Positive Impact 15

16 Acute Myocardial Infarction Risk Adjustment Factors (Must be POA) Protein calorie malnutrition (*21) Dementia (*51 53) Vascular disease (* ) Valvular heart disease (*86) Cardioresp failure/shock (*84) Hemiparesis/hemiplegia (*70 74) Amputation status (LE, UE) (*189/190) Congestive heart failure (*85) Met cancer, acute leukemia (*8, 9) Major psych disorders (*57 59) Renal failure (CKD) (* ) COPD (*111) Pneumonia (* ) Chronic liver disease (27 29) Trauma in past year (* & ) Stroke (*99 100) Diabetes/diabetic disorders (*17 19 & 123) History of CABG Other MI (second site) Age per year >65 Male * Hierarchical Condition Categories version 22 16

17 COPD: Risk Adjustment Factors (Respiratory Failure) Protein calorie malnutrition Dementia Vascular disease Valvular heart disease Cardioresp failure/shock Congestive heart failure Met cancer, acute leukemia Pneumonia Decubitus ulcer Pleural effusions/pneumotx Anemias Arrhythmias Electrolyte disorders Fibrosis of lung Endocrine disorders Ventilation 17

18 Congestive Heart Failure Risk Adjustment Factors Protein calorie malnutrition Dementia Vascular disease Valvular heart disease Cardioresp failure/shock Hemiparesis/hemiplegia Met cancer, acute leukemia Major psych disorders Pneumonia Renal failure COPD Chronic liver disease Trauma in past year Acute MI Male 18

19 Pneumonia: Risk Adjustment Factors (Sepsis) (Excluding Severe Sepsis) Protein calorie malnutrition Dementia Vascular disease Cardioresp failure/shock Hemiparesis/hemiplegia Congestive heart failure Met cancer, acute leukemia Major psych disorders Renal failure Chronic liver disease Decubitus ulcer Trauma in past year Pleural effusion/pneumotx Electrolyte disorders Stroke Seizure disorder/convulsions Parkinson s/huntington s Delirium & encephalopathy Male Severe hematological disorders Vertebral fracture 19

20 Factors That Impede Risk Adjustment Documentation Erlanger is a tertiary regional care center AMI and stroke patients are transferred from other hospital emergency departments to Erlanger for a higher level of care Primary focus is patient care and saving their life Patients flown in from outlying EDs with very little documentation of history Family adjusting to acuity of illness, not the time to ask: Has your loved one lost weight recently? Would you be interested in hospice care today?* *If patient is transferred to hospice before 1 st midnight, they are excluded. 20

21 Factors That Impede Risk Adjustment Documentation Hospitalist and consultant diagnoses conflict Residents NP, PA Electronic record Copying and pasting Problem list Lack of understanding of the importance of documentation of diagnoses that are POA Identification of the PDX, lack of understanding of the significance of that diagnosis 21

22 Case Study #1 Patient admitted with pneumonia and severe sepsis, AKI Coded to: Sepsis, pneumonia both POA Severe sepsis with septic shock coded as not POA, since part of the code not POA Progress notes on day 2 reflect septic shock Clinical validation of mortality chart: ED documentation: Lactic acid 3.89 with acute respiratory failure Query assigned; response: Septic shock was POA 22

23 Case Study #2 Admitted with chief complaint of SOB x 1 day Coded to acute diastolic heart failure Clinical findings: Pt with history of CHF, diabetes, hepatitis C infection status post Harvoni and hepatocellular carcinoma. Physical exam: Effort normal. No respiratory distress. He has no wheezes. Abdomen: Exhibits distension. CXR: Interstitial pulmonary edema. CT abdomen: New moderate to large volume abdominopelvic ascites, new moderate left pleural effusion, and new diffuse anasarca. BNP on admission 672. Hepatic congestion: Bilirubin is greater than 5. Will diurese him. Will get BNP and new echo. SOB: 2/2 Abdominal distension 2/2 large volume ascites vs. CHF. Echo mildly reduced EF and grade II diastolic dysfunction. 23

24 Case Study #2 (cont.) #1) SOB, possibly due to massive distension secondary to large volume ascites vs. CHF vs. left pleural effusion Clinical validation by physician suggested query to the attending for clarification of the PDX Attending s response: Both acute on chronic systolic heart failure and end stage liver disease due to hepatitis C, cirrhosis, and hepatocellular carcinoma recurrence Changed PDX to cirrhosis 24

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26 Polling Question #1 When two diagnoses equally meet the definition of principal diagnosis and one of them is one of the five mortality risk adjusted diagnoses, do you feel it is acceptable for a hospital to educate their coding staff to select the non star rating diagnosis as principal? Yes, and we do educate Yes, but we don t currently do this No, you would go with the higher weighted diagnosis No, we follow a different process for assigning PDX in this situation 26

27 Summary Deficient documentation affects physician practices and hospitals financially Inpatient and physician practice documentation needs are similar: Highest degree of specificity Must reflect monitoring, evaluation, and treatment Consistent documentation across the healthcare spectrum will lead to an accurate risk adjustment score for HCCs and for hospital quality measures 27

28 HCCs Link Plans/MedicareAdvtgSpecRateStats/Risk Adjustors.html 28

29 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. 29