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1 Myth vs. Fact: Misconceptions About Pediatric CDI Programs Daxa Clarke, MD Lucinda Lo, MD Amy Sanderson, MD Sheilah Snyder, MD 1 Daxa Clarke, MD Medical Director, CDI & UM Phoenix Children s Hospital Phoenix, AZ Lucinda Lo, MD Physician Advisor, CDI Program Children s Hospital of Philadelphia Philadelphia, PA Amy Sanderson, MD Physician Advisor, CDI Program Boston Children s Hospital Boston, MA Sheilah Snyder, MD Physician Champion, CDI Program Children s Hospital & Medical Center Omaha, NE Drs. Clarke, Lo, Sanderson, & Snyder have no relevant financial relationships to disclose. 2 Learning Objectives At the completion of this educational activity, the learner will be able to: Differentiate between adult CDI and pediatric CDI Describe the potential financial and quality impacts of a pediatric CDI program Describe the potential impact of the ICD 10 implementation at pediatric hospitals 3

2 DRGs and CMI Daxa Clarke, MD Sheilah Snyder, MD 4 Steps for Attendees to Answer/View POLLING QUESTIONS 1. Navigate to the event Agenda in the main menu 2. Tap the name of the current session to view the session details page 3. Tap Polls 4. Tap the name of the poll 5. Tap your answer choice and then tap Submit 5 Polling Question 1 Pediatrics uses MS DRG for the majority of their patients. True False 6

3 False Majority of pediatric payers use APR DRG 7 Definitions DRG Diagnostic Related Group A system to classify hospital cases into groups Based on ICD 10 diagnostic and procedure codes MS DRG (Medical Severity/Medicare) APR DRG (All Patient Refined/AHCCCS) 8 MS DRG Terms CC complication/comorbidity (CMS list: 94 pages) MCC major complication/comorbidity (CMS list: 52 pages) Base DRG without CC or MCC Base DRG with CC Base DRG with MCC 9

4 APR DRG Terms SOI severity of illness Extent of organ system derangement or physiologic decompensation Minor (1), moderate (2), major (3), extreme (4) Affects reimbursement 10 APR DRG Terms ROM risk of mortality Estimate of the likelihood of in hospital death Minor (1), moderate (2), major (3), extreme (4) Infrequently affects reimbursement 11 DRG Reimbursement Payment rates Medicare: Rate is set nationally by CMS Medicaid: Rate is set state by state Private payers: Rate both variable and negotiable 12

5 Financial Impact of Pediatric CMI Case mix index Value that represents an average DRG relative weight for a particular hospital Determines the allocation of resources to treat patients in that group 13 Omaha Children s Case Mix Index Source: PHIS 14 National CMI Data From PHIS 15

6 Omaha Children s Case Mix Index Monthly CMI 0.5 YTD CMI 0 Jul 14 Aug 14 Sep 14 Oct 14 Nov 14 Dec 14 Jan 15 Feb 15 Mar 15 Apr 15 May 15 Jun 15 Jul 15 Aug 15 Sep 15 Oct 15 Nov 15 Dec Diagnostic Definition Dilemmas Lucinda Lo, MD Amy Sanderson, MD Sheilah Snyder, MD 17 Polling Question 2 There is a standard definition of acute respiratory failure in pediatrics. True False 18

7 True or False? False 19 Acute Respiratory Failure Pediatric workgroup lunch at ACDIS 2015 Pediatric respiratory failure workgroup Goal: Acute respiratory failure definition 20 Pediatric Acute Resp Failure Definition Modified from Texas Children s criteria: The inability to provide O2 and remove CO2 at a rate that meets metabolic demands Traditionally: PaO2 < 60, O2 sat < 88% on RA, acute increase of PaCO2 > mmhg 21

8 Pediatric Acute Resp Failure Definition Any of the following interventions: FiO2 > 40% to maintain sats > 90% O2 delivery >/= 2L/min for </= 12 mo 4L/min for </= 24 mo 5L/min for > 24 mo Any BIPAP, CPAP, HFO2 (except for isolated OSA) 22 ARF Reference List 1. Hammer J. Acute respiratory failure in children. Paediatric Respiratory Reviews (2013). 14: Roca O, Riera J, et al. High flow oxygen therapy in acute respiratory failure. Respir Care (2010). 55: Sztrymf B, Messika J, et al. Impact of high flow nasal cannula oxygen therapy on intensive care unit patients with acute respiratory failure: a prospective observational study. J Critical Care (2012). 27: 324.e9 e Dani C, Pratesi S, et al. High flow nasal cannula therapy as respiratory support in the preterm infant. Pediatric Pulmonology (2009). 44: British Thoracic Society standards of care committee. Noninvasive ventilation in acute respiratory failure. Thorax (2002). 57: Hess DR. Noninvasive ventilation for acute respiratory failure. Respiratory Care (2013). 58: Najaf Zadeh A and Leclerc F. Noninvasive positive pressure for acute respiratory failure in children: a concise review. Annals of Intensive Care (2011). 1: Teague WG. Non invasive positive pressure ventilation: current status in paediatric patients. Pediatric Respiratory Reviews (2005). 6: Frat J P, Thille AW, et al. High flow oxygen through nasal cannula in acute hypoxemic respiratory failure. N Engl J Med (2015). 372: Polling Question 3 Hypotension is a required criterion for both adult and pediatric septic shock. True False 24

9 Septic Shock False Hypotension is a late sign of shock in pediatric patients and is not necessary for the diagnosis. Goldstein B, Giroir B, Randolph A, et al. Pediatr Crit Care Med 2005; 6:2. Kissoon N, Orr R, and Carcillo J. Pediatr Emerg Care 2010 Nov; 26(11): Levy M, Fink M, Marshall J. Intensive Care Med 2003 Apr; 29(4): Septic Shock May be clinically diagnosed in pediatric patients who: Have a suspected or known infection AND Have clinical signs of inadequate tissue perfusion after adequate fluid resuscitation ( 40 ml/kg) Goldstein B, Giroir B, Randolph A, et al. Pediatr Crit Care Med 2005; 6:2. Kissoon N, Orr R, and Carcillo J. Pediatr Emerg Care 2010 Nov; 26(11): Polling Question 4 BMI is diagnostic for both adult and pediatric malnutrition. True False 27

10 Pediatric Malnutrition False Z scores are used to diagnose malnutrition in pediatric patients Z scores used in malnutrition: Weight for length BMI for age Length/height Reference Source: 28 Malnutrition Diagnosis: Abbreviated Age Based Criteria 29 Clinical Examples Paraparesis Pancytopenia Malnutrition Respiratory failure Urosepsis 30

11 Paraparesis 12 mo with lumbar myelomeningocele, Chiari II malformation, neurogenic bowel & bladder. Query sent for paraparesis. Physician responded, Myelomeningocele with paraparesis. 31 Impact: Paraparesis Diagnoses Queried diagnosis Before query Myelomeningocele, Chiari II malformation, neurogenic bowel & bladder Myelomeningocele After query Myelomeningocele, Chiari II malformation, neurogenic bowel & bladder Myelomeningocele with paraparesis APR DRG assignment SOI 2 (moderate) 3(major) ROM 1 (mild) 2(moderate) Relative weight Expected reimbursement (assume BR $5,000) $7,700 $11,250 ( $3,550) 32 Opportunities in Oncology CDI 16 year old has acute myeloid leukemia (AML) Admitted for chemotherapy per road map Neutropenic Required platelet and RBC transfusions due to cytopenias Dietitian note: Acutely malnourished, moderate 6 kg (equals 13 pound) weight loss 10% of body weight in less than 1 month 33

12 Impact: Pancytopenia, Malnutrition, & Oncology Remission Before query After query Diagnosis Chemotherapy Chemotherapy Queried diagnoses AML, unspecified if in remission Malnutrition Cytopenias APR DRG SOI 2 (moderate) 4 (extreme) ROM 2 (moderate) 3 (major) Relative weight AML, in remission Malnutrition, moderate Pancytopenia induced by chemotherapy Expected reimbursement $8,000 $16,500 ( $8,500) 34 Impact: Malnutrition & Respiratory Failure 17 yo with Ewing's sarcoma with tracheal compression requiring baseline home BIPAP Admission for respiratory distress with increased BIPAP needs Then requires tracheal stenting to maintain airway Discharged home on higher BIPAP settings Weight 36 kg = 79 pounds Dietician note: Patient presents with BMI below healthy range for adults, and weight loss of 9% in past 2 months, indicating acute, severe malnutrition 35 Impact: Malnutrition & Respiratory Failure Before query After query Diagnoses Tracheal compression Ewing's sarcoma Tracheal stent Tracheal compression Ewing's sarcoma Tracheal stent Respiratory distress Acute on chronic Queried respiratory failure diagnoses 36 kg = 79 pounds Severe malnutrition APR DRG SOI 3 (major) 4 (extreme) ROM 2 (moderate) 3 (major) Relative weight Expected reimbursement $12,500 $26,000 ( $13,500) 36

13 Urosepsis 15 year old male with myelomeningocele, hydrocephalus s/p VP shunt, neurogenic bowel & bladder with recurrent UTIs admitted for fever and lethargy. The patient was admitted with enterococcus urosepsis. Query sent and the physician answered, Sepsis due to a urinary tract infection. 37 Impact: Urosepsis Diagnoses Before query Myelomeningocele, neurogenic bladder & bowel, recurrent UTIs After query Myelomeningocele, neurogenic bladder & bowel, recurrent UTIs Queried diagnosis Urosepsis Sepsis due to UTI APR DRG assignment SOI 3 (major) 3 (major) ROM 1 (mild) 1 (mild) Relative weight Expected reimbursement $3,500 $5,200 ( $1,700) 38 Impact of ICD 10 on Pediatric Institutions Examples: Loss of acute respiratory distress Procedural codes 39

14 Loss of Acute Respiratory Distress Code ICD 9 Acute respiratory distress (code 51882) SOI: 2 (moderate) ROM: 1 (mild) ICD 10 Dyspnea (code R0600) SOI: 1 (mild) ROM: 1 (mild) 40 Procedural Codes ICD 9 About 3,000 codes Often the diagnosis & procedure are IN the code ICD 10 Procedure Coding System About 87,000 codes Congenital malformations 41 Summary: The Truth About Pediatric CDI Programs! Pediatric CDI programs differ from adult programs given the predominantly non Medicare pediatric population Pediatric CDI programs face unique challenges Relatively small number of DRG payers Lack of uniform diagnostic definitions Pediatric CDI is still a developing field 42

15 Summary: The Truth About Pediatric CDI Programs! Despite these challenges, pediatric CDI programs are important and can positively impact pediatric institutions!!! 43 Thank you. Questions? Daxa Clarke, MD = Dclarke@phoenixchildrens.com Lucinda Lo, MD = LOL@ .chop.edu Amy Sanderson, MD = amy.sanderson@childrens.harvard.edu Sheilah Snyder, MD = shsnyder@childrensomaha.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. 44