CDQI RN: Data Quality Improvement Local ACDIS Chapter Meeting October 6, 2016 Erin Nelson, CDQI RN, BSN, CCRN Clinical Documentation Integrity Program Swedish Medical Center

Agenda 1. CMS Emphasizes Quality Over Quantity of Care 2. Evolution of Pay-for-Performance Programs 3. Creation & Usage of Claims-Based Quality Metrics 4. CDQI Role Genesis 5. CDQI Impact Potential on Claims-Based Quality Metrics 6. CDQI Role Key Objectives, Tactics & Strategies 7. CDI vs CDQI Role Differences 8. CDQI Focus Areas & Targeted Interventions (case examples removed from disseminated version) 9. Swedish Quality CDI Work Samples (removed from disseminated version) 10. References 11. Q&A

Progression of CMS Healthcare Landscape The Changing Landscape CMS is transitioning from volume of service to quality of service Previous State CMS: Current & Future State CMS: Fee-For-Service Pay-For-Performance Alternative Payment Models Population Based Payment Traditional Model DRG payment Separate payment for each service performed Episodes of Care with “Package Pricing” Bundled Payment Programs Per CMS: Increases care coordination Reduces duplication Reduces unnecessary care Clinicians & Organizations are paid for beneficiary care over a period of time Volume of service and payment are not linked Fee-For-Service payments Fiscal penalties applied to all Medicare base DRG payments when there is poor quality performance

Evolution of Pay-For-Performance Programs Value Based Purchasing HAC Reduction Program Hospital Readmission Reduction Program Core Measures Meaningful Use “Rewarding hospitals for delivering services of higher quality and higher value” Medicare.gov 2002 2009 2010 Affordable Care Act

Quality Performance Scores Medicare Receives & Processes Claim CDQI Claims Based Quality Measures Explained Quality Performance Claim is used to determine performance in certain quality measures Quality Performance Scores Performance is measured over a rolling 3 year period Publically Reported Performance Quality performance results released to Hospital Compare website CMS Response to Complications of Care: Immediate: Will decline to pay for the increased cost of care associated with a HAC. -and- Delayed: Hand down fiscal penalty for poor quality performance scores. Start Inpatient Admission Clinicians document throughout admission Claims-Based Quality Measures are included in Pay- for- Performance programs: Value Based Purchasing (VBP) Hospital Readmission Reduction Program (HRRP) HAC Reduction Program (HACRP). Financial Penalty Poor performers incur a penalty Patient Discharged Inpatient Coder Receives chart for coding Coding Completed Inpatient coder finalizes coding claim & sends to Medicare Medicare Receives & Processes Claim Claim is used to determine reimbursement Payment Swedish receives payment for hospitalization Reimbursement END

CDQI Role Catalyst Why CDQI?: A CDI focused approach on quality metrics has proven to result in improvement in overall data quality. After success with PSI 15 focus, the CDQI role was created to focus specifically on quality metrics for analysis and improvement. CDI vs CDQI Scope CDI RN: Broad Documentation Integrity CDQI RN: Quality Metrics Focus

Quality Performance Scores Medicare Receives & Processes Claim CDQI Intervention Quality Performance Claim is used to determine performance in certain quality measures Quality Performance Scores Performance is measured over a rolling 3 year period Publically Reported Performance Quality performance results released to Hospital Compare website Start Targeted Review for Claims-Based Quality Metric Integrity Inpatient Admission Clinicians document throughout admission Financial Penalty Poor performers incur a penalty Patient Discharged Inpatient Coder Receives chart for coding Coding Completed Inpatient coder finalizes coding claim & sends to Medicare Medicare Receives & Processes Claim Claim is used to determine reimbursement Payment Swedish receives payment for hospitalization Reimbursement END

Timeline: Claims-based Quality Measures METRIC 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 ACA passed VBP & HRRP Starts HACRP Starts 30- DAY MORTALITY VBP AMI HF Pneumonia COPD Stroke CABG VBP VBP Likely future VBP addition 30-DAY READMISSION HRRP AMI HF Pneumonia THA/TKA COPD CABG Stroke HRRP HRRP Affordable Care Act 2010- ACA passed -> creation of Pay-for- Performance Programs THA/TKA 30-Day Readmission 2015- officially added as a metric to the Hospital Readmission Reduction Program THA/TKA Complications Will be added to VBP starting in FY2019 Performance period 2019- 30 months retrospective (2016 is already included!!!) 2020- 36 months retrospective CJR Bundled Payment Program April 2016- First performance period begins HRRP HRRP LEGEND HRRP Metric Added to Pay-For-Performance Program Likely future HRRP addition COMPLICATIONS Metric Added to IQR VBP THA/TKA VBP & HACRP Metric Dry Run PSI 90

One Year Lingers in Pay-for-Performance Scoring PROGRAM CLAIMS -BASED METRIC FY 2017 BASELINE PERIOD FY 2017 PERFORMANCE PERIOD Value Based Purchasing 30-Day Mortality: AMI Heart Failure Pneumonia Oct. 1, 2010 – June 30, 2012 Oct. 1, 2013 - June 30, 2015 PSI 90 HAC Reduction Program N/A July 1, 2013 - June 30, 2015 Hospital Readmissions Reduction Program 30-Day Readmission HF THA/TKA COPD CABG July 1, 2012 - June 30, 2015 Example Poor HRRP performance in 2015 impacts scores for 4 fiscal years: FY2017 (7/1/12-6/30/2015) FY2018 (7/1/13-6/30/2016) FY2019 (7/1/14-6/30/2017) FY2010 (7/1/15-6/30/2018)

Value Based Purchasing FY 2017 ACA established. Program kicked-off in 2013 POOR PERFORMERS Maximum penalty 2% of all Medicare base DRG payments HIGH ACHIEVERS Incentive payments Up to 2% of all Medicare base DRG payments Measures Communication with nurses Communication with doctors Responsiveness of hospital staff Pain Management Communication about medicines Cleanliness & quietness Discharge information Overall rating of hospital Patient Experience of Care 25% Safety 20% Clinical Care 30% Efficiency & Cost Reduction 25% Medicare Spending Per Beneficiary Measures Outcomes: 30- day Mortality: AMI, HF, PNA Process: AMI 7a IMM-2 PC-01 Measures AHRQ PSI-90 Composite CAUTI CLABSI C.diff infection MRSA SSI: Colon surgery Abdominal Hysterectomy Process 5% + Outcomes 25% CDI IMPACT POTENTIAL

VBP Financial Implications Fiscal Year Percent Reduction 2016 1.75 2017 2.0 Succeeding Years Eligibility requirements 2016: must meet threshold in 2/4 domains 2017: must meet threshold in 3/4 domains All eligible hospitals: Medicare payments are reduced by set percentage of base MS-DRG payment Only CMS program in which a hospital can make money Hospital earns bonus or penalty based on: Achievement points Improvement points Consistency points FY 2016 Net Percentage Change Maximum Penalty - 1.75 Average Change Between -0.4 to + 0.4 Maximum Bonus Slightly more than + 3

VBP CDI Impact Potential 30-Day Mortality AMI HF PNA AHRQ PSI-90 Composite PC-01 Elective C-section at 37-39 weeks gestation Medicare Spending Per Beneficiary HCC Risk Adjustment MS-DRG assignment Claims Based Patient Experience of Care Press Ganey survey Clinical Care Process Measures Hospital Acquired Infections SSI- Colon surgery, Abdominal Hysterectomy CAUTI CLABSI MRSA C. diff Infection NOT Claims Based VS

DRA HAC Measure Reporting Hospital-Acquired Conditions: 2 CMS Programs Creation Measures $ Penalty DRA HAC Measure Reporting 2005 Deficit Reduction Act (DRA) 14 HACs in 11 Categories Immediate HAC Reduction Program 2010 Affordable Care Act (ACA) PSI 90 Composite Delayed

Hospital-Acquired Condition (HAC) Reduction Program Bottom 25% of performing hospitals incur 1% penalty on all Medicare base DRG payments CDI IMPACT POTENTIAL PSI 90 COMPOSITE Claims Data HAC Reduction Program DOMAIN 1 Established by ACA Started in 2015 FY 2016: 15% of Total HAC Score TOTAL HAC SCORE CLABSI NHSN Data Not Claims-Based DOMAIN 2 CAUTI FY 2016: 85% of Total HAC Score SSI

Patient Safety Indicator (PSI) 90 Composite Key Takeaway PSI 90 is a Composite of Indicators used in the HAC Reduction Program & Value Based Purchasing Provides a perspective on patient safety Complication or adverse event Developed by AHRQ 27 PSIs 11 PSIs within the AHRQ PSI 90 composite 8 PSIs recognized by CMS in the PSI 90 composite. These 8 are NQF endorsed  PSI 90 Composite

PSI 90 Version 6.0 PSI Metric Modified Metric Added X PSI 3- Pressure Ulcer Rate PSI 6- Iatrogenic Pneumothorax Rate PSI 8- In-Hospital Fall with Hip Fracture Rate X PSI 9- Perioperative Hemorrhage or Hematoma Rate PSI 10- Postoperative Acute Kidney Injury Rate PSI 11 – Postoperative Respiratory Failure Rate PSI 12- Perioperative PE or DVT Rate PSI 13- Postoperative Sepsis Rate PSI 14- Postoperative Wound Dehiscence Rate PSI 15- Unrecognized Abdominopelvic Accidental Puncture/Laceration Rate

PSI 90 FY2016 Changes- v6.0 Spotlighted Changes Description *** CMS has not adopted the new changes yet, CMS is still using v5.0 Spotlighted Changes Description There was a name change Changed from “Patient Safety of Selected Indicators Composite” to “Patient Safety and Adverse Events Composite” to capture the concept of patient harm resulting from the event The number of component indicators increased from 8 to 10 PSI 7- CLABSI was removed PSI 9,10 & 11 were added. Changes were made to PSI 8, 12 and 15. PSI 8- Now includes all hip fractures from inpatient falls, not just those that occur postoperatively PSI 12- Isolated calf vein DVT was removed as a numerator specification. Patients with any diagnosis of acute brain and/or spinal injury were removed from the denominator specifications. PSI 12 events may be less preventable due to safety concerns with pharmacological prophylaxis PSI 15- Refined to focus on most serious intraoperative injuries due to an acc punc/lac. Denominator is now limited to abd/pelvic sx. Name change to “Unrecognized Abdominopelvic Accidental Puncture/Laceration Rate” In depth info on FY2016 PSI 90 changes: http://qualityindicators.ahrq.gov/News/PSI90_Factsheet_FAQ.pdf

Hospital Readmission Reduction Program (HRRP) ACA established. Program kicked-off in 2013. POOR PERFORMERS Maximum Penalty 3% penalty to all Medicare base DRG payments Metric Populations Outcome Metric Planned Readmission Algorithm Identifies readmissions that are excluded All-Cause Unplanned 30-day Readmission Condition Specific AMI HF Pneumonia COPD Procedure Specific THA/TKA CABG Inclusion Criteria Medicare FFS Part A & B Enrolled for at least 12 months Age 65+ Exclusion Criteria Discharged AMA Planned Readmissions Exclusions variable based on Population. For example, THA/TKA unplanned readmission exclusions: More than two THA/TKA procedure codes during index Concurrent revision or resurfacing procedure Transfers to another acute care facility PDX- Mechanical complication PDX- Malignant neoplasm POA fracture Removal of implanted devices/prostheses

SUMMARY Claims-Based Measures, Program Penalties, & CDI Impact Potential CLAIMS -BASED METRICS CLAIMS-BASED METRICS –PROGRAM SCORE IMPACT FY 2017 MAX $$$ PROGRAM PENALTY Value Based Purchasing 30-Day Mortality: AMI Heart Failure Pneumonia Likely additions: COPD, Stroke PSI 90 THA/TKA Complications Approximately 35% *** Outcomes 25% + Safety Measures 20% (includes NHSN metrics) 2% HAC Reduction Program 15% 1% Hospital Readmissions Reduction Program 30-Day Readmission HF THA/TKA COPD CABG 100% 3%

CDI & CDQI Scope & Focus Areas Scope of CDI & CDQI Process MD documents Inpatient coder codes chart Claim sent to insurance company Reimbursement & Quality Data Role Focus: Missing or conflicting documentation Failure to rule out a diagnosis Incorrect code assignment Over/underreporting of certain diagnoses Denials RAC audit Overpayment Underpayment CMI inaccurate Inaccurate Quality Data CDI Missing exclusion criteria Missing documentation of risk factors Missing POA status Confusing documentation around potential complications Incorrect PDX assignment Missing or incorrect code assignment POA status incorrect Over/underreporting of complications Inaccurate claims data Inaccurate Quality Data O:E PSI Mortality Readmissions CDQI

CDQI Strategy, Tactics & Objectives Core Objective: Break down process and communication barriers to allow for a consistent coding experience in order to ensure data integrity, driving major decision making across the organization. Envision and execute process changes to quality metrics documentation and coding Efficient communication channel between providers & coding staff Tell a story about data trends enabling medical professionals to take action What? Improve Swedish Quality Outcomes Build accuracy & trust in data Identify abnormal trends Why? Build process and tools to enable coders to accurately code charts Educate providers around key components and pitfalls of data quality process Provide documentation feedback to providers specific to quality metrics How?

CDQI Focus Areas PSI 90 Mortality Erin Nelson CDQI RN Objectives Key Players PSI 90 Mortality Readmissions Misc. Consultation Establish clear process for review Become subject matter expert Identify common documentation and coding pitfalls and collaborate on solutions Coding department CDI department Quality department Physician champions Establish clear review process for mortalities Become subject matter expert Identify common documentation and coding pitfalls and collaborate on solutions Coding department CDI department Quality department Physician champions Establish clear review process for readmissions Become subject matter expert Identify common documentation and coding pitfalls and collaborate on solutions Coding department CDI department Quality department Physician champions Erin Nelson CDQI RN Consistent Resource, Presence, & Liaison with Quality Department Quality Department Various departments

Patient Safety Indicators PSI 90 Current State Desired Future State Established PSI Process Flow: 1. Identification: PSI 15 & 12- Stop billed All other NQF endorsed PSI 90- Jvion & Premier 2. Case Review & Provider query 3. Coding Recommendation 4. Track Impact & Trends 5. Documentation solutions: Stop-Bill on all PSI cases pending CDQI review CDI Physician coordinator driven MD education Pressure Ulcer SmartPhrase DVT drop down menu DVT/PE Documentation Presentation B. CDI departmental education: Departmental meeting presentations Reference notebook Individual discussions Current State: Established PSI Review Process Flow Identification: PSI 15 & 12- Stop billed All other NQF endorsed PSI 90- Jvion & Premier Coding Recommendation Track Impact & Trends Excel spreadsheet shared with colleague in Quality Department Case Review & Provider query Documentation solutions CDI Physician coordinator driven MD education : Pressure Ulcer smartphrase autopopulates POA status and stage from WOC RN note, DVT drop down menu requires specificity and POA documentation in DCS, CDI Physician Coordinator DVT/PE Documentation Presentation CDI departmental education: departmental meeting presentations, reference notebook, individual discussions Ideal State: 1. Stop-Bill on all PSI cases pending CDQI review Barriers: PSI Query Response 2. CMS only recognizes top 25 codes Mitigation Strategies: MD Champions, Escalation Process Resequence codes to ensure exclusion codes are in top 25 codes. Barriers Mitigation Strategies 1. Provider PSI Query Response 2. CMS only recognizes top 25 codes MD Champions, Escalation Process Re-sequence exclusions in top 25 codes.

30-Day Mortality Current State Desired Future State Retrospective mortality review Reviewing CHF mortalities as concurrently as possible Identification: See Case Review process flow (on future slide) Track Impact & Trends Excel spreadsheet shared with colleague in Quality Department Documentation Solutions: Stop-Bill on all CMS Condition-specific and Procedure-specific mortalities (PENDING) Risk adjustment review infused in concurrent CDI review A. CDQI-driven Provider education Understanding the metric Documentation for O/E optimization B. CDI MD Coordinator : Template work SmartPhrases Drop down menus Mitigation Strategies Current State: Established PSI Review Process Flow Identification: PSI 15 & 12- Stop billed All other NQF endorsed PSI 90- Jvion & Premier Coding Recommendation Track Impact & Trends Excel spreadsheet shared with colleague in Quality Department Case Review & Provider query Documentation solutions CDI Physician coordinator driven MD education : Pressure Ulcer smartphrase autopopulates POA status and stage from WOC RN note, DVT drop down menu requires specificity and POA documentation in DCS, CDI Physician Coordinator DVT/PE Documentation Presentation CDI departmental education: departmental meeting presentations, reference notebook, individual discussions Ideal State: 1. Stop-Bill on all PSI cases pending CDQI review Barriers: PSI Query Response 2. CMS only recognizes top 25 codes Mitigation Strategies: MD Champions, Escalation Process Resequence codes to ensure exclusion codes are in top 25 codes. Designated accountable providers MD Education: O/E optimization. Template work: make risk variables easy to capture. Re-sequence risk variables to top 25 codes. Barriers Labor intensive Multiple provider groups report diagnoses Premier reporting system does not refresh corrected cases CMS only recognizes top 25 codes

30-Day Readmissions Current State Desired Future State Retrospective readmission review Identification: Premier Vantage CDQI case review: Low hanging fruit: fix cases with wrong PDX, request added codes for documented risk variables Identify mixed documentation of risk variables Track Impact & Trends Consultative reviews Ongoing readmission reviews Feedback to MD group Presentations Individual discussions Concurrent Readmission Capture Risk adjustment review infused in concurrent CDI review Mitigation Strategies Current State: Established PSI Review Process Flow Identification: PSI 15 & 12- Stop billed All other NQF endorsed PSI 90- Jvion & Premier Coding Recommendation Track Impact & Trends Excel spreadsheet shared with colleague in Quality Department Case Review & Provider query Documentation solutions CDI Physician coordinator driven MD education : Pressure Ulcer smartphrase autopopulates POA status and stage from WOC RN note, DVT drop down menu requires specificity and POA documentation in DCS, CDI Physician Coordinator DVT/PE Documentation Presentation CDI departmental education: departmental meeting presentations, reference notebook, individual discussions Ideal State: 1. Stop-Bill on all PSI cases pending CDQI review Barriers: PSI Query Response 2. CMS only recognizes top 25 codes Mitigation Strategies: MD Champions, Escalation Process Resequence codes to ensure exclusion codes are in top 25 codes. Designated accountable providers MD Education: O/E optimization. Template work: make risk variables easy to capture. Re-sequence risk variables to top 25 codes. Barriers Labor intensive Multiple provider groups report the diagnosis Premier reporting system does not “refresh” to reflect changes CMS only recognizes top 25 codes

How CMS Determines the “Expected” Outcome Performance Scoring Criteria Observed Outcome Predicted Outcome Condition-Specific POPULATION = = Expected Outcome Expected Outcome *CMS speak for O/E CMS Expected Outcome Methodology Age CMS-derived Hierarchical Logistic Regression Model Sex Expected Outcome = Comorbid disease Patient Frailty

30-Day Readmission & 30-Day Mortality- CDQI Impact Potential CDQI Intervention CDQI Impact Aggregate Effect Principal Diagnosis Verification Identify Missing Risk Variables Eliminates incorrect observed cases Accurately reflect expected outcome Accurate O/E ratio Hospital Wide Observed Outcome Expected Outcome Specified Population Observed deaths = Higher than 1 Expected deaths Risk Factor (Missing) Incorrect PDX The Patient (CDI) Level 1 (The deceased) Risk Factor (missing) Relative Expected Mortality (REM) = Risk Factor (missing) Risk Factor (Missing) Comorbidity 1 Comorbidity 2 Comorbidity 3 (Missing) Risk Factor (Missing) Risk Factor (Missing) Incorrect PDX Risk Factor (Missing)

CMS Risk Adjustment Example: AMI 30-Day Mortality Measure Risk Adjustment Variables CMS-derived Hierarchical Logistic Regression Model Coefficients: Age Comorbid disease Indicators of Patient Frailty Source: Inpatient Outpatient Physician Medicare administrative claims data 12 month look back + index admission “Expected” Mortality after AMI : CMS-derived Hierarchical Logistic Regression Model Comorbid disease -> only those clinically relevant and which have a relationship with the potential outcome of AMI mortality. CMS’s regression model does NOT take into account socioeconomic status. This differs from Premier’s risk adjustment model called “Care Science Analytics” which incorporates things like income, distance from hosital, etc. So the data that Premier captures will be close to what our CMS numbers are but not exactly. The different methodologies account for differences in the O/E. Additionally, make sure that when you look at the data presented to you: see if it includes ALL AGES and ALL INSURANCE PAYERS because this will reveal very different data than if you’re just looking at the CMS population Risk- adjustment variable capture: 12 months prior to, and including, the index admission.

Risk Adjustment Drill Down CC= Condition Category Grouping of similar diagnosis codes into diseases that are related clinically and with respect to cost Example: AMI 30-Day Mortality Risk Adjustment Variables The presence of a code from a CMS-identified CC will incrementally increase the risk of the expected outcome DRILL DOWN: Renal Failure (CC 131) ICD-9 Code Code Description CC CC Description Chronic Kidney Disease, Stage II is Documented Code is contained within CC 131 CC 131 is an identified CC for the AMI 30-Day Mortality Metric Increase in Expected Mortality Improvement in O/E

Case-Level Review Process Adjudication Flow CMS Mortality Chart Review Chart Addendum and Coding Recommendations Loop Closure & Coding Reconciliation Expectations: Manages Stop-Bill work queue. Notifies clinician Reviews documentation within 2 business days. Identifies coding variances Identifies potential missing risk factor documentation & discusses with MD Notifies coding of potential coding variances Notifies coding of MD chart note addendums Tracks occurrence of requested coding changes Updates spreadsheet CQDI Receives notification of patient mortality by CDQI RN. Reviews documentation within 2 business days. Ensures PDX diagnosis appropriate Chart note addendums to: clarify inappropriate PDX diagnosis add missing risk factor documentation. MD to MD communication Follows spreadsheet. Clinician

References AHRQ CMS Quality Net PSI Resources Value Based Programs http://www.qualityindicators.ahrq.gov/modules/psi_resources.aspx CMS Value Based Programs https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/Value-Based-Programs.html Quality Net Claims Based Measures https://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier2&cid=1228763452133

Questions? Erin.Nelson@Swedish.org