NCHIMA 66 th Annual Meeting Transforming Todays CDI Model to - - PowerPoint PPT Presentation

NCHIMA 66th Annual Meeting

Transforming Today’s CDI Model to Support Value Based Payments

James Fee, MD, CCS, CCDS Vice President Shannon Newell, RHIA, CCS Director CDI Quality Initiatives

Objectives

Participants in this session will:

• Understand how documentation and code assignment impact

the selection and risk adjustment of encounters included in claims based quality measures linked to payment

• Gain insights into the increasing alignment of physician and

hospital interests in accurate and complete documentation

• Identify CDI Program evolution requirements to effectively

support clinical documentation impactful in today’s value based payment era

• Move away from payment for volume
• Improve care coordination
• Promote alignment of financial and
• ther incentives to increase the quality
• f care and lead to better outcomes

Background

CMS Payment Model Evolution

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HHS Secretary Burwell Posting January 2015 Goals ‐ increase % of Medicare provider payments linked to quality

• utcomes and alternate payment

models

• Quality: 2016 85%  2018 90%
• APMs: 2016 30% 2018 50%

Lower Cost Improve Quality

Background

CMS Payment Model Evolution (cont)

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• Payment
• Public profiles
• Performance
• Patient Care

The Impact of CDI on Value Based Outcomes

ICD Code

• Hospital Pay for Performance Programs

Risk‐adjusted claims based outcome measures include:

• Patient Safety Indicator (PSI) 90
• Mortality Rates
• Readmission Rates
• THA/TKA Complication Rates
• Medicare Spending Per Beneficiary (MSPB)

Background

Category 2 – Fee for Service Link to Value

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FY HACRP HVBP HRRP Overall 2015 1.00% 1.50% 3.00% 5.50% 2016 1.00% 1.75% 3.00% 5.75% 2017 1.00% 2.00% 3.00% 6.00%

• Cohort

– Inclusions – Exclusions

• Risk Adjustment

Pneumonia Mortality

Inpatient/Ambulatory CDI Impact

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Risk Standardized Mortality Rate Pneumonia (v9.2) – Effective FY 2017 (IPPS FY2015)

Inclusion

• Pneumonia as principal diagnosis, or
• Sepsis as principal diagnosis with

pneumonia as other diagnosis (POA) Exclusions

• Severe sepsis as SDx (POA)
• Discharged AMA

Risk Adjustment of Entire Cohort

MCANCER MALNUTRITION HEMATOLICAL DISORDER DEMENTIA RESPFAILURE FIBROSIS LUNG LIVERDIS CHF HXMI

…29 risk adjustment comorbid category groups

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ID discharges in cohort ID actual observed all cause mortality within 30 days Risk adjust cohort (CMS) Predicted/Expected 12 month “lookback”. Part A & B claims. “Complications”

Key takeaway ‐ All discharges in the cohort “count” in the measure; not limited to mortalities

Pneumonia Mortality

Inpatient/Ambulatory CDI Impact (cont)

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24.42% 17.09% 8.26% 6.81% 5.20% 4.83% 4.55% 4.05% 3.62% 3.44% 3.42% 3.05% 2.31%

0.00% 5.00% 10.00% 15.00% 20.00% 25.00% 30.00%

MCANCER… MALNUTRITION… DEMENTIA LIVERDIS CARDIO_RESPIRATORY… CHF… HEMATOLOGICAL… IRON_DEFICIENCY… FIBROSISLUNG… PARALYSIS_FUNCTDIS… HxMI VERTEBRAL_FRACTURES PsychDIS

Risk Standardized Pneumonia Mortality Comorbid Categories with 90% Risk Adjustment Impact

Pneumonia Mortality

Inpatient/Ambulatory CDI Impact (cont)

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Pneumonia Mortality

Suboptimal Comorbidity Capture

• Clinical documentation and/or code reporting opportunities?

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Pneumonia Mortality

Risk Adjustment – CMS vs. APR‐DRG

CMS P4P Program Outcome Measure Population CMS APR‐DRG IQRP Mortality CABG N/A IQRP HVBP FY2021 Mortality COPD HVBP Mortality HF HVBP Mortality MI HVBP Mortality Pneumonia IQRP Mortality Stroke N/A

• Different risk adjustment methodologies – different results

• Physician fee schedule adjustments
• Providers are rated on four criteria weighted and scored to create a

composite score; the score adjusts provider fee for service reimbursement

Background

Category 2 – Fee for Service Link to Value

Data in 2017 impacts performance in 2019

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Merit‐Based Incentive Payment System (MIPS) Physician Quality Reporting System PQRS Value Based Modifier Program VBM Meaningful Use Electronic Health Record Incentive Program Certified HER Technology CEHRT Calendar Year 2019 2020 2021 2022 Physician Fee Schedule Adj +/‐ 4% +/‐ 5% +/‐ 7% +/‐ 9% Incentive 27%

Value Based Modifier (VBM)

Inpatient/Ambulatory CDI Impact

• Acute composite index

– Hospital admissions with select acute diagnoses

• Bacterial pneumonia
• UTI
• Dehydration

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Bacterial Pneumonia Principal Diagnosis Codes

Value Based Modifier (VBM)

Inpatient/Ambulatory CDI Impact

• Chronic composite index

– Hospital admissions with select chronic diagnoses

• Short term complications ‐

diabetes

• Long term complications ‐

diabetes

• Uncontrolled ‐ diabetes

– Diabetes may be secondary diagnosis if patient had a lower extremity amputation

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Diabetes Principal Diagnosis Codes ‐ Excerpts

Value Based Modifier (VBM)

Inpatient/Ambulatory CDI Impact

• Medicare spending per

beneficiary measure (MSPB)

• Part A and Part B costs
• Immediately prior to, during, and

for 30 days following a qualifying stay

• Risk adjustment methodology ‐

Hierarchical Condition Categories (HCC)

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The HCC risk adjustment methodology is also utilized by payers (Medicare Advantage, some commercial) to determine physician payment rates.

• HCCs are hierarchical categories used to predict healthcare

expenditures of individuals

• CMS calculates risk for a member based on the following:

– Demographics (i.e. Age, Sex) – Reported (ICD‐10) diagnoses (chronic conditions)

• Reported diagnoses are used to prospectively adjust capitation

payments for a given enrollee/member based on them enrollee/member’s health status.

HCC Impact on Payment

Medicare Advantage

Diagnosis codes are submitted on claims Risk scores are calculated Risk Adjustment Factor (RAF) impacts reimbursement for next calendar year

HCC Impact on Payment

Medicare Advantage ‐ Example

No HCC Diagnoses Some HCC Diagnoses ALL HCC Diagnoses

76 y.o. female 0.317  0.317  0.317 Medicaid eligible 0.189  0.189  0.189 Diabetes 0.121 Diabetes w/ renal 0.368 CKD,IV 0.297 CKD, IV 0.297 Protein cal malnutrition 0.731 CHF 0.362 Paraplegia 0.9595 BKA status 0.793 PEG status 0.659 DM+CHF+Renal 0.600 RAF 0.506 0.924 5.2755 Estimated Annual Payment $4,858 $8,870 $50,645 Base Rate: $800/month Note: Values are for illustrative purposes only

HCC 17 Diabetes with Acute Complications 0.378 HCC 17 Diabetes with Acute Complications 0.378

• Diabetes, Type I with ketoacidosis

HCC 18 Diabetes with Chronic Complications 0.378 HCC 18 Diabetes with Chronic Complications 0.378

• Diabetes, Type I with renal

manifestations, u/c

HCC 19 Diabetes w/o

complication

0.121

• Diabetes,

unspecified

HCC Impact on Payment

Medicare Advantage – Example (cont)

Note: Values are for illustrative purposes only

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Physician Performance

Quality Resource Utilization Report

• Clinical documentation and/or code reporting opportunities?

• The Comprehensive Care Joint Replacement Payment Model (CJR)

Background

Category 3 – APM Build on Fee‐for‐Service Infrastructure

Quality Composite Score Above target price

Performance Year episode cost reconciliation

Hospital repayment Hospital reconciliation payment Below target price

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• Mandatory bundled payment for defined

episode of care

• 90 day episode
• Total joint replacements lower extremity

(MS‐DRGs 469, 470)(Includes fractures)

• Two sided payment model
• Hospital accountable for financial risk
• April 1, 2016 through December 31, 2020

• All related services/ items paid under Medicare Part A or Part B

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Included Services

• Physicians' services
• Inpatient hospitalization (including readmissions)
• Inpatient Psychiatric Facility (IPF)
• Long‐term care hospital (LTCH)
• Inpatient rehabilitation facility (IRF)
• Skilled nursing facility (SNF)
• Home health agency (HHA)
• Hospital outpatient services
• Outpatient therapy services
• Clinical laboratory services
• Durable medical equipment (DME)
• Part B drugs and biologicals
• Hospice services

Source: CMS CJR Final Rule

CJR

Costs Included in the Episode

• All related services/ items paid under Medicare Part A or Part B

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Source: CMS CJR Final Rule

CJR

Costs Excluded in the Episode

Excluded Services*

• Certain inpatient admissions
• Certain Part B services
• Services and clotting factors for

hemophilia

• Inpatient new technology payments
• Outpatient transitional pass‐through

payments for devices Inpatient readmissions excluded using MS‐DRGs. Categories:

• Oncology
• Trauma medical
• Chronic disease surgical, e.g.,

prostectomy

• Acute disease surgical, e.g..,

appendectomy

Part B services excluded using principal ICD‐10 code. Categories:

• Acute disease – e.g., severe head

injury

• Chronic disease – selected on

diagnosis basis based on likelihood

• f impact by LEJR

• The Comprehensive Care Joint Replacement Payment Model (CJR)

Quality Composite Score Above target price

Performance Year episode cost reconciliation

Hospital repayment Hospital reconciliation payment Below target price

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CJR

Quality Outcomes ‐ Impact on Payment

• Repayment – Must repay Medicare
• Reconciliation payment – Eligible to receive

“savings”

• Quality composite score determines:
• Eligibility for reconciliation payment
• Amount of repayment or reconciliation

payment (through reduction of up to 50% of the CMS 3% discount)

• THA/TKA Risk Standardized Complication Rate (RSCR) (50%)
• Patient satisfaction surveys
• Patient reported data

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%ile Rank RSCR Comp Points Patient Exp Points PRO Data Subm Points >90th 10.00 8.00 2.00 >80th and <90th 9.25 7.40 2.00 >70th and <80th 8.50 6.80 2.00 >60th and <70th 7.75 6.20 2.00 >50th and <60th 7.00 5.60 2.00 >40th and <50th 6.25 5.00 2.00 >30th and <40th 5.50 4.40 2.00 <30th 2.00 Improvement 1.0 .80 N/A

CJR

Quality Outcomes ‐ Impact on Payment (cont)

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What is It

• Risk adjusted measure to estimate the rate of defined

complications with elective primary THA and TKA Population (Cohort)

• ICD‐10 procedure driven (total hip, total knee)
• Exclusions: partial hips; fractures, other

Complication Timeframe for occurrence AMI Within 7 days of index admission admit date Pneumonia Same as above Sepsis/septicemia/shock Same as above Surgical site bleeding During index admission or within 30 days of admit date PE/DVT During index admission or within 30 days of admit date Death During index admission or within 30 days of admit date Mechanical complications During index admission or within 90 days of admit date Peri‐prosthetic joint/ wound infection Same as above

Risk Standardized Complication Rate

(RSCR)

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Qualifier (Remove from Numerator) ICD‐10 Code Field (Index Adm Only) Fracture – femur, hip, pelvic Principal Diagnosis (PDx) or Other Dx POA Mechanical complication PDx Malignant neoplasm – pelvis, sacrum, coccyx, lower limbs, or bone/bone marrow, or a disseminated malignant neoplasm PDx Partial hip arthroplasty (PHA) Procedure Resurfacing procedures Procedure Revision procedures Procedure Removal of implanted devices/prosthesis Procedure Transfers from another acute care facility N/A Exclusions (Remove from Denominator) ICD‐10 Code Field (Index Adm Only) > 2 THA/TKA procedure codes Procedure Discharged AMA N/A

RSCR (cont)

Exclusions

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RSCR (cont)

Risk Adjustment Comorbidities

16.99% 7.65% 6.62% 4.82% 3.65% 2.96% 2.89% 2.38% 2.20%

0.00% 5.00% 10.00% 15.00% 20.00%

MALNUTRITION… OBESITY… ESRD_DIALYSIS… Athero PNEUMONIA RENAL_FAILURE PARALYSIS_FUNCTDIS… CARDIO_RESPIRATORY… VASDIS_WCOMP… RHEUMATOID_ARTHRITIS or… VERTEBRAL_FRACTURES Other congenital deformity of hip… Osteoporosis and other… Osteoarthritis of hip or knee PLEURALEFFUSION

Comorbid Category Group Risk Adjustment Impact THA/TKA Complications

“Malnutrition” “Cachexia” “Morbid

• besity”

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• Documentation and reported codes across the continuum impact

payment for hospitals and physicians

• CDI Programs must evolve beyond MS‐DRGs and APR‐DRGs to

support data quality relevant to these outcomes across the continuum

Value Based Claims Outcomes

The Impact of (and on) CDI Programs

CDI Across the Continuum Patient Centered Around Episodes

• f Care

CDI Across the Continuum

Quality Measure Priorities

What Measures / Methodologies?

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http://content.healthaffairs.org/content/34/3/423.abstract

Standard Set of Measures

CMS and 70% Payers – February 2016

https://www.cms.gov/Medicare/Quality‐Initiatives‐Patient‐Assessment‐ Instruments/QualityMeasures/Core‐Measures.html 31

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CDI Medical Record Reviews Provider Engagement Documentation Infrastructure Performance Monitoring CDI Program

CDI Program Charter

• To promote and support the capture of provider clinical documentation

essential to the accurate reporting of patent complexity for quality profiles and reimbursement

CDI Program Evolution

Leading Practice Indicators

• Awareness of health system leadership team of

CDI impact on value based outcomes across continuum

• Expertise on claims based measures and CDI

vulnerabilities

• Engagement of CDI Team in collaborative
• rganizational improvement initiatives
• Awareness of providers of CDI impact on value

based outcomes across the continuum

• Expansion of CDI team record review support

(scope of review, population, setting)

• Leverage of documentation infrastructure to

promote and support point of care documentation capture

• Meaningful performance metrics to measure,

monitor, and focus continual improvement

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CDI Program Evolution

Data Driven Focus

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Summary

• Value based outcomes derived from claims data link quality and

cost performance to reimbursement

• Clinical documentation and reported ICD‐10 codes directly

impact value based outcome performance

• Seize the opportunity to evolve your CDI Program to meet these

new challenges

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