trizetto provider solutions july 15, 2015 joy king ewing, rhia, ccs, ccds joy king consulting, llc1

TriZetto Provider SolutionsJuly 15, 2015

Joy King Ewing, RHIA, CCS, CCDS

Joy King Consulting, LLC 1

Reimbursement Physician Profiles Utilization Patterns--SI/IS (InterQual), OBS Severity of Illness Data--includes mortality

& complication rates Provider Profiles & Report Cards Payer/Managed Care Contracts

Ewing/Scott 2

INCREASED SCRUTINY


Bundled Payments—Hospitals & MDs have to share the reimbursement

Condition-Specific Capitation ModelEpisode of Care ModelAccountable Care OrganizationsManaged Care


Increasing Medicare revenue requires a) increasing taxes OR b) taking budgeted govt funds from other programs

SO, cost-cutting is the focus, with◦increased focus on medically unnecessary

procedures and admissions◦Increased recovery of overpayments◦Linking payment to “quality”—severity-

adjusted patient outcomes Other payers following suit


Coders pressured to determine if Clinical Indicators present before coding diagnoses documented by the MD◦ Pneumonia without infiltrate on CXR◦ Sepsis with no documentation showing criteria are

met◦ “acute” episode of chronic conditions documented

without clinical evidence in record (CHF, Resp Failure)

Inadequate documentation in the EMR to provide real clinical support for diagnoses in Progress Notes, Discharge Summaries

Some RACs focusing on high-level E/M codesJoy King Consulting, LLC 7

CHANGES IN REIMBURSEMENT RATES


Hospital-acquired Conditions (HACs) & Core (Quality) measures

Hospital Length of Stay Hospital Costs Patient Safety Indicators (PSI 90) Mortality Rates Readmission Rates Office Visit Costs/# Visits per Patient—

justification for E/M & CPT codes billed These all reflect severity/complexity ranking


Performance profiling Economic credentialing & profiling Disease management profiling Physician billing compliance

Healthcare Purchasers identify efficient MDs by data mining from claims to measure performance relative to established benchmarks


Why is improved clinical documentation important to MDs?

In October 2014, Medicare will start collecting data to modify MD reimbursement

There will be a 2% reduction for every Medicare payment if Medicare considers the MDs costs too high—Value-Based MD Payment Modifier to be phased in 2015-2017


How to factor Quality into the Economic Profiling that is

Occurring


Work Harder (see more patients)

More effectively collect what is billed

Document better, so that it can be accurately translated into codes that reflect severity/complexity—severity profiling will determine future MD reimbursement rates


ICD-10 includes greater specificity to risk adjust data◦ More accurate, meaningful estimates about

what a disease state or procedure costs to treat◦ Includes demographic and social issues

impacting patients’ health

Reimbursement more accurately re-aligned with complexity and costs to treat complex cases


Has it improved documentation??

“What is being diminished or even eliminated is the 100-yr old tradition of narrative that tells the story of the patient’s condition in a manner that is easy to understand and remember. Even long-time MDs have abandoned the clinical narrative & simply click a line or two in the EMR.” Dr. Juan Cueva, Cook County Medical Society

Ewing/Scott 15

Dr. Jonathan Elion, speaker at Clinical Coding Meeting in San Diego believes “cut & paste is NOT a good idea—bad information gets repeated over & over

Two places appropriate for cut & paste: 1) radiology report interpretations pasted into PN, 2) pathology report results pasted into PNNO need to cut & paste from PN to PN


Electronic PN: aside from what meds, test results, lab values cut & pasted—are problems & response to treatment clear?

MDs entering codes in the EMR—is a legal document, wrong codes can be liability risk

MD offices: incorrect diagnoses or codes to hospitals for pre-authorization, medical necessity, approval of tests/services ordered & scheduled

Billing wrong site of service (MD office vs. OP/Ambulatory Surgery Center)


E/M levels may increase due to use of EMR◦ May be due to ease of documenting (templates,

drop-down boxes) Pay attention to drop-downs!◦ Make sure documentation is clinically supported

OIG study on impact of EMR on coding◦ Authentication—OIG did not let reviewers count

anything in the study that was not signed within 48 hrs of the patient’s appointment time

Inaccurate Coding: Some payers are giving MDs bonus points for reimbursement if they employ a certified coder


Documentation should clearly tell the patient’s story—especially in hybrid MR

The Discharge Summary should NOT tell a different story than the Progress notes, Consults, etc. do, e.g. not including resolved diagnoses in Final Diagnoses List


“Should” explain the resources used to treat the patient

Should provide clinical rationale for treatment in the IP setting, as opposed to OBS

Should provide a comprehensive description of the hospital stay

Should include instructions for continued care to relevant care givers

ARE YOUR DISCHARGE SUMMARIES A GOOD INVOICE FOR ALL SERVICES

BILLED?


Must demonstrate the patient’s progress towards treatment goals, or

Demonstrate patient’s findings or changes in condition

Certification of two midnights and IP order alone do NOT guarantee medical necessity

Information within the MR about the patient’s condition—NOT JUST THE DIAGNOSIS—support necessity of IP vs. OP services



Documentation needs to reflect: Disease etiology Acute vs. chronic, acute on chronic Failure vs dysfunction or insufficiency Stages of disease progression of chronic

conditions, e.g. diabetes mellitus linked to complications◦ Document acute manifestations/exacerbations ◦ Document decompensation or debility of chronic

diseases

“due to” or “manifested by”

MDs best insurance policy to demonstrate the quality of their care AND medical necessity:◦ Shows analytical skills◦ Problem-solving skills◦ Complexity of decision-making involved in the

patient’s care #, acuity and severity/duration of problems

addressed through Hx, PE, and medical decisions

Context of the encounter among all other services previously given for the same problem


Based on ICD-9 Dx Code and CPT E/M LevelBronchitis acute 466.0 99221 $ 65.01Bronchitis w/ COPD 491.21 99222 $106.74Bronchitis/COPD/ARF 518.81/491.21 99291 $163.85

E/M Level submitted needs to match the specificity/severity of the ICD-9 Diagnosis submitted—is now impacting reimbursement along with CPT codes


MDs need to be taught Concepts of

Documentation


Sustained & ongoing education Succinct & clinically relevant to them

◦ Not what “should” be documented◦ Individual information on what they are not

documenting◦ Identify documentation issues by provider◦ Provide each with a workable list of their

documentation issues◦ Consider mobile apps that can keep their

documentation issues list updated◦ Include medical necessity, severity/acuity issues

Use PA’s and Service line MD leaders


Contributing Factors to Costs◦ LOS◦ Tests◦ Consultants called◦ Medications—MDs don’t know costs of meds but it

affects their payer scorecards

Mortality Rates◦ If 3 of 10 cases expire (observed mortality) where

documentation only supports 1 of 10 (expected mortality)—their mortality rate is 3x expected

◦ This can be improved JUST by improving quality of documentation, assuming quality of care acceptable


Ewing/Scott 28

I-9

I-10

Increased code specificity requires substantial documentation changes

More robust definitions of severity, comorbidities, complications, sequelae, manifestations, causes, and other parameters that describe the patient’s condition

25% of additional ICD-10-CM codes due to including laterality

25% of additional codes due to distinguishing between “initial” & “subsequent” encounters

Ewing/Scott 29

Inappropriate to select a more specific code that is not supported by documentation

Inappropriate to order medically unnecessary tests to obtain a more specific diagnosis code


OP & Ambulatory SurgeryMAC payments to facilities being aligned to MD payments—if hospital claim denied, MD claim can be alsoPayers refusing to pay for “unspecified” diagnoses given as reason for proceduresWhich MDs have documentation leading to NOS codesDon’t offer NOS, “unspecified sites, etc. as options on templates & check sheets


Unspecified diagnosis codes◦ 80% of codes on claims are secondary diagnoses◦ Emphasize importance of secondary diagnoses in

showing complexity/severity◦ # unspecified codes used in ICD-9 is less than for

ICD-10 Focus on additional documents needed for

ICD-10 specificity◦ Radiology reports Vent sheets◦ Medication records therapy notes◦ Transfusion records dialysis notes


For both ICD-9 and ICD-10Accurate reflection of acuity & severity of illnessSeverity of illness should match intensity of services provided and vice versaAccurate justification for resources consumedAccurate reflection of factors used to measure MD efficiency, outcomes, risk adjustment, quality, and costs of care


Should be documented if they are evaluated, monitored, treated or affect your treatment plan, e.g. Syncope or Chest pain

BUT Should not be used as a final diagnosis

unless no definitive cause is found


Document Comorbidities, e.g. Diabetes Mellitus, Type II, Severe Malnutrition, etc.

Any condition that affects patient care in any one of five ways:◦ Clinical Evaluation◦ Diagnostic Evaluation◦ Therapeutic intervention◦ Increased level on monitoring◦ Disposition

Secondary Diagnoses may raise the DRG Severity Level if documented to appropriate degree of specificity.


Do not use Fever of Unknown Origin. If treated with antibiotics and it resolves, use suspected cause at discharge, e.g. “Possible ___ Infection”. List specific type, etc.◦Probable Sepsis◦Probable Mixed Bacterial Pneumonia◦Possible Gram-negative Pneumonia◦Probable Aspiration Pneumonia

Document what you have been treating as the likely problem


Patient admitted for major bowel procedure. Patient had secondary dx of CHF. Actual LOS 9 days

As documented, stay grouped to DRG 331 Major bowel proced w/o MCC/CC

GMLOS 4.8 days

If MD documented chronic diastolic heart failure (CC), groups to DRG 330 GMLOS 7.8 days

If MD documented acute on chronic diastolic heart failure, groups to DRG 329 GMLOS 12.5 days

Ewing/Scott 37

Principal Diagnosis

Colitis

Secondary Diagnosis AnemiaAKICKD, Unspecified

DRG 392 w/o MCCSOI/ROM: 2/1

DRG r.w. 0.7375LOS 2.8 days


Adm for COPD exacerbation w/ acute bronchitis. Stools occult +; EGD confirmed gastritis.

PDX: COPD exacerbationSecondary Dx: GastritisMS DRG 192 COPD w/o CC/MCC r.w. 0.7072

$3,690 2.9 LOS

Secondary Dx: Gastritis, GI bleedMS DRG 191 COPD w/ CC r.w. 0.9521

$4,967 3.6 LOSSecondary Dx: GI bleed due to gastritisMS DRG 190 COPD w/ MCC r.w. 1.1860

$6,183 4.3 LOS


Problematic Clinical Diagnoses:◦ CHF (systolic vs. diastolic)—unspecif doesn’t

show exacerb◦ Sepsis/SIRS (severe, organ failures linked)◦ DM (manifestations/complications, Type I or II)◦ Acute Kidney Disease specificity◦ Chronic Kidney Disease (stages)◦ Pneumonia (link to organism or aspiration)◦ CAD (chest pain vs. angina vs. CAD)◦ Decubitus ulcers vs. Other ulcers (stage, POA)◦ GI bleed linked to GI cause◦ Malnutrition or Obesity (severity)


Pneumonia

Urosepsis Bacteremia MODS or Sepsis

Syndrome Diabetes Anemia Malnutrition

AMS or delirium

Aspiration Pneumonia, Probable Gram – Pneumonia

Sepsis due to UTI Sepsis Severe sepsis w/ Resp failure

& Acute Kidney Failure Type 2 DM w/ PVD & ulcer Acute blood loss anemia Severe protein-calorie

malnutrition Metabolic Encephalopathy


Diagnosis Specificity Needed Respiratory Failure Acute, w/ hypoxia or

hypercapnia Asthma Severity Level of Asthma Myocardial Infarction Coronary artery involved Stroke/CVA Specific artery involved Aftercare following injury Specific injury Injuries Specific site & laterality Open Fractures Gustilo open fracture scale


Document the clinical evidence and documentation in the chart for AKI

“Do you feel the patient has AKI?”◦ ____Yes◦ ____No◦ ____Clinically unable to determine (provide the

criteria for AKI on the query since MDs often don’t know the criteria


1 2 3 4 5 6 7

Section

Body System

Root Operation Approach

Device

Qualifier

Body Part/Region

Ewing/Scott 44

One ICD-9-CM procedure code = multiple ICD-10-PCS codes

Additional specificity required:◦ Specific information on devices—most

frequently missing piece of information◦Surgical approaches clearly documented◦Specific anatomical sites involved 2nd most frequently missing element Will impact CC/MCC status of code,

e.g. part of foot in an amputations


There are no “unspecified” procedure codes

Specificity to fully assign each character of the code = more frequent queries

Requires Very Specific Body Part Requires Laterality Requires Specific Approach Requires Specific Type of Contrast Material Requires Specific Procedures performed which

have been defined by “eponyms” in ICD-9 (Whipple procedure)

46Joy King Consulting, LLC

“In times of rapid change, experience could be your worst enemy” (J Paul Getty)

“No problem is too big or so complicated that it cannot be run away from!” (Charlie Brown)


Contact Information:

Joy King Consulting, [email protected]

(205) 612-4471


trizetto provider solutions july 15, 2015 joy king ewing, rhia, ccs, ccds joy king consulting, llc1

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