Creating Success Through Collaboration: How Coding, CDI, and Quality Align May 12, 2016

Creating Success Through Collaboration St. Vincent is a member of Ascension Health, the largest Catholic health care system in the country. St. Vincent has 22 health ministries serving 57 counties in central and southern Indiana. St. Vincent has 3 large state-of –the –art hospitals, 8 critical access hospitals, 7 specialty hospitals along with numerous joint venture partnerships and clinical affiliations. May 10, 2016

The build up Around March 2010, with the implementation of the Affordable Care Act, Denial patterns changed – multiple denials on similar issues brought scrutiny; opportunity to trend data and denials skyrocketed with the new environment The ACA authorized HHS to release data to promote transparency in the market place which in turn developed the comparative data scramble – how to make your health system shine? The driver of the data was the Electronic Health Record frenzy – via the HITECH Act of 2009 – billions were funneled to EMR adoption Now everyone can monitor care and care-outcomes http://www.healthdata.gov/

The build up Resulted in regulation upgrades which in turn created a need for highly trained coding specialists to work the denials Pay for performance creates a paradigm of expected positive outcome – coding specialists needed for validating high-risk accounts for review Entities involved: RAC, OIG, CMS, Private payers, QIO, OPPE programs, AHQR, NHS Example of a CMS communication back in 2010- https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MedQtrlyComp_Newsletter_ICN904943.pdf

The build up The power of data began to be unleashed As more systems became electronic – mining for data became a potential source of benchmarking CMS began developing programs that would link reimbursement with payment for Core Measures, Meaningful Use, etc. By responding to these mandates – the hospital system bought into the process of care-based data driving future reimbursement levels for the Medicare population Providers are now getting inline with the current model for pay- for-performance

Late to the party Where was data being reported? How was the data being filtered? How was data being reacted to – who was at the table? 2011 – RAC influence in hospital cultures began Getting it straight – terminology, approach, information dissemination, knowing the team members move beyond the Rev Cycle Using retrospective data to insure prospective fiscal soundness A new age of awareness for the value of partnership between coding, CDI and Quality

Coding Collaboration Pre Collaborative Process Patient Safety Indicator cases were flagged in the internal auditing system. There was no set process or standard on how these were reviewed. PSI rates were not communicated to auditing staff. There was an internal complication policy in place to provide directions to coding staff. The policy would directly affect the PSI indicators identified as complications if followed.

Coding Collaboration First Focus Review: PSI #11Postoperative Respiratory Failure Cases were reviewed from the previous fiscal year that were reported as qualifying for PSI #11. Cases were first reviewed by an independent auditing company for validation. Identify challenges and differences between two different coding systems: ICD-9 vs. ICD-10 The findings were verified internally. Data was extrapolated to identify any trends for areas of improvement. The findings were communicated with the coding, auditing and CDI staff along with education.

Coding Collaboration Sample Data extrapolation for St. Vincent Indianapolis PSI #11 cases

Coding Collaboration Barriers Current Process Transition to ICD -10-CM is not a 1:1 mapping process. No standardized process for reviewing PSI cases among auditors. Cases were identified after billing which resulted in extra work and data validity was at risk. Complication policy was tailored to ICD-9-CM. Complex reviews require clinical reviews Current Process Ongoing ICD-10-CM education. Coders receive individual feedback. All cases flagged for PSI are deposited into a work queue and reviewed by dedicated auditor. Cases are not billed until reviewed and any outstanding issues resolved within timely billing limits. Policy is being updated jointly by coding and CDI. There is a dedicated CDI nurse available for PSI reviews.

How reporting in a ministry matters Determine the entire data reporting process What systems involved Who gather data and scrubs Identify points in process to escalate PSI flag issue How to get updated materials recorded/overlay Insure that data fields are validate and correct – i.e. POA of “N” on pressure ulcers at St. Vincent ministry – caused a outlier status on that PSI Currently we expect all data to be resubmitted to Premier every month to insure most up-to-date materials are uploaded

Why is This So Important? Complete documentation is reflective of the true severity of your patients and care provided for your patient… Support the length of stay, medical necessity & continuity of care Reflects severity of illness (SOI) and risk of mortality (ROM) scores Precise data capture for public reporting Physician profiles are developed from documented information

Effect of Documentation on Outcomes 331 Major Small and Large Bowel Procedure WO CC/MCC Rel Wt Exp Mort Exp LOS Exp Cost Exp Readmit Exp Payment Secondary DX CHF 1.64 0.13% 5.67 $12851 8.93% $10,824 330 Major Small and Large Bowel Procedure W CC Rel Wt Exp Mort Exp LOS Exp Cost Exp Readmit Exp Payment Secondary DX Chronic Systolic Failure 2.57 0.73% 7.79 $16681 12.25% $16,962 330 Major Small and Large Bowel Procedure W CC Rel Wt Exp Mort Exp LOS Exp Cost Exp Readmit Exp Payment Secondary DX Chronic Systolic Failure 2.57 0.73% 7.79 $16681 12.25% $16,962 329 Major Small and Large Bowel Procedure W MCC Rel Wt Exp Mort Exp LOS Exp Cost Exp Readmit Exp Payment Secondary DX Acute Systolic Failure 5.26 9.51% 13.59 $30,302 18.69% $34,716

What This Means for Physicians Your “quality” will be measured and disclosed to the public Quality metrics/outcomes will be severity adjusted Failure to Document: Implications Medico–legal risk Failure to document severity of illness will lead to underpayment and a poor profile Failure to document medical necessity for services provided – risk of non-payment or erroneous payment “recovery” (RAC audit)

Why Good Documentation Matters As of October 1, 2015, 65 percent of value-based purchasing (VBP) scores, 25% of the new hospital-acquired conditions (HAC) payment reduction program and 100% of the readmission reduction program scores will be derived from coded data Educate your CDI/Coding/Quality staff on the Patient Safety Indicators

Quality Documentation Work as a TEAM Changing the Model Coding Team Physicians CDI Team Quality Documentation Finance Quality Billing Nursing Case Managers

Summary The key to improved documentation is a successful relationship among coders, quality staff and CDSs Work together to educate providers on quality documentation to meet guidelines Make sure everyone understands what HACs and PSIs are Review reported HACs and PSIs on a regular basis as a team to identify trends Track your DRG denials and modify your education efforts accordingly Provide feedback on opportunities for improvement

Mary Girard, RHIT, CCSP, System Manager Coding Mary.Girard@stvincent.org Lee Walton , RN, MHA,CCM,CCDS, System Manager CDI lawalton@stvincent.org Erin Blankenship, CCS, Coding Quality Auditor Erin.Blankenship@stvincent.org