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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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.

8. 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.

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

10. 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.

11. 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

12. 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

13. 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

14. 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)

15. 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

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

17. 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

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