Ambulatory/OP CDI on a Poor Man’s Budget

Caryl Liptak, MSHAI, RHIALori Ganote, MSN, RN, CCDSBaptist Health Kentucky RHIA

Who is Baptist Health?

Baptist Health is a mission driven, full-spectrum health system dedicated to improving the health of the communities we serve. We offer comprehensive care that includes traditional inpatient hospital services, outpatient surgery centers and physician offices, and also provides convenient, accessible care through urgent care and Express Care clinics, home care, and new outreach programs in the community.

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Baptist Health History

94 years strong

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1924-2018

What We Do

8 Hospital Facilities Approx. 1100 Employed ProvidersAcute care/Rehab/Psychiatric Primary Care CentersLong Term Acute Care Home Health/Hospice/Palliative CareSkilled Nursing Care Occupational Medicine (BaptistWorx)Emergency Care Health PlanOutpatient Care Physician Network(hospital, Urgent Care, Baptist Baptist Employer SolutionsExpress Care, Diagnostic Centers) Ambulatory Surgery CentersWellness/Fitness Centers PT Sports Medicine CentersAmbulance Services FoundationsOutpatient Cancer Radiation Centers

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Where We Are

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Polling Question:Do you have an Ambulatory/OP CDI program?

How Did It All Begin?

• Resource Council Meeting• Goal was to establish outpatient CDI• Move from financial CDI program to quality-based CDI program

• Recognition of need• Attending meetings related to ambulatory CDI• Collaboration with insurance company • Risk adjustment audits• HCC concept discussed at local meeting• ACDIS conference • HCCs, VBP, risk adjustment became familiar terms

Outpatient CDI vs Ambulatory CDI

• Executive director separates the two• Ambulatory CDI: physician practice side• Outpatient CDI: hospital side

• Decision made to begin with Ambulatory CDI• Audits showed some physician practices had low RAF scores • Documentation was not capturing HCCs• Chronic conditions requiring yearly documentation

• How could inpatient CDI help?

Polling Question:Are you familiar with HCC's?

HCCs: Why Do They Matter?

• Hierarchical Condition Categories (HCC)• Risk adjustment methodologies:

• Insurance companies receive reimbursement for the illness burden of a particular patient

• Some health plans in turn share this increased revenue with providers• Using just CMS-HCCs should capture at least 90% of the risk adjustment for inpatient and

outpatient programs• Used to determine reimbursement for various Medicare plans• Addresses predominately elderly population (65 and over)• Captured by claims submitted inpatient and outpatient

HCC Impact

• Risk Adjustment Factor (RAF) scores to predict future healthcare costs for plan enrollees

• Adjust payment based on the health status and demographic characteristics of the enrollee

• Chronic conditions• Age• Gender• Institutionalization status• Medicaid status • Current reason for Medicare eligibility

• CMS pays participating health plans a monthly capitation payment based on CMS-HCCs

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Comparison Heart Failure and Diabetes

• Enrollee, 65 years old, male no disability = 0.295• Factor 1: Chronic diastolic HF, HCC 85 = .0317• Factor 2: AKI with tubular necrosis, HCC 135 = 0.415• Factor 3: Disease interaction HCC 85 and renal = 0.266

• Risk score =0.295 + 0.317 + 0.415 + 0.266

• Total risk score: 1.293

• Enrollee, 66 years old, male, no disability = 0.295 • Factor 1: Diabetes without complications, HCC 19 =0.102• Factor 2: Heart failure, NOS, HCC 85 = 0.317• Factor 2: Alcoholic cardiomyopathy, HCC 85• Factor 3: Disease interaction DM*CHF = 0.151

• Risk score = 0.295 + 0.102+ 0.317 + 0.151

• Total risk score: 0.865

CMS P4P Measures Risk Adjustment with HCCs

Program # of Risk-Adjusted Measures

Incentive/Penalty

Value-Based Purchasing 6 of 21 +2% to -2%

Readmission Reduction 7 of 7 Up to -3%

HAC Reduction 1 of 7 -1%

Value Modifier ~50% +32 to -2%

Merit-based Incentive Payment System (MIPS)

Very Few +4% to -4%

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Development of Process

• Education• Management team• Auditors/educators• CDI staff• Coding staff (task force meeting)• Dinner and educational lecture for physicians

• Operating with limited budget• Staff• Education• Software for outpatient

Education On HCC Impact

• 8 hospital system • 350-400 employed physician practices

• Specialty groups• Hospitalist• Cardiology• Ortho

• Peer-to-peer education• Ancillary departments

• Wound care nurses• Dieticians• Quality

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CCC42%

MCC16%

HCC

ConditionCategories

TOP 5

• BMI <19 or >40 and corresponding diagnosis• CHF, acuity and specificity• Malnutrition• Diabetes associated complication or chronic condition(s)• Primary and secondary cancers

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TOP 5

We recognize the following:• Most commonly known as “chronic” conditions• 42% of HCC’s are also CC’s• 16% of HCC’s are MCC’s• These conditions also affect SOI/ROM for the in-patient encounter• Affect the RAF scores for the calendar year• Help provide an accurate description of patient care and utilization of

resources• Affect Quality programs • MOST IMPORTANTLY…WE ALREADY DO IT!

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HCCs Familiar to Cardiology

HCC # Description

HCC 17 Diabetes with Acute Complications

HCC 18 Diabetes with Chronic Complication

HCC 19 Diabetes without Complication

HCC 83 Respiratory Arrest

HCC 84 Cardio-Respiratory Failure and Shock

HCC 85 Congestive Heart Failure

HCC 86 Acute Myocardial Infarction

HCC 87 Unstable Angina and Other Acute Ischemic Heart Disease

HCC 88 Angina Pectoris

HCCs Familiar to Cardiology

HCC # Description

HCC 96 Specified Heart Arrhythmias

HCC 100 Ischemic or Unspecified Stroke

HCC 106 Atherosclerosis of the Extremities with Ulceration or Gangrene

HCC 107 Vascular Disease with Complication

HCC 108 Vascular Disease

HCC 111 COPD

HCC 135 Acute Renal Failure

HCC 136 Chronic Kidney Disease (Stage 5)

HCC 137 Chronic Kidney Disease, Severe (Stage 4)

Hospitalist HCC Tip Card

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In-patient Tip Card• HCC In-Patient General List:• Abuse/Dependence (alcohol/cannabis/opioid) • Atrial Fibrillation (paroxysmal/persistent/chronic) • Cardiomyopathy (ischemic/non-ischemic, dilated/hypertrophic)• Cerebrovascular accident CVA (ischemic, hemorrhagic, thrombotic, embolic)• Chronic Kidney Disease (stage I-V/ESRD, etiology, on dialysis)• Acute Kidney Failure (KDIGO criteria, ATN)• Chronic Obstructive Pulmonary Disease (emphysema, chronic bronchitis)• DVT/PE (acute, chronic, recurrent, current, history of, date when, location)• Diabetes Mellitus (type, stable, secondary complications of)• Heart Failure (acute, chronic, acute on chronic, systolic, diastolic, combined, etiology if known)• Depression (major/bipolar, paranoid disorders, mild/moderate, /severe, part/full remission)• Malnutrition/protein-calorie malnutrition (mild, moderate, severe)

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In-patient Tip Card• HCC In-Patient General List:• Myocardial Infarction (STEMI/NSTEMI, dates, current/recurrent) • Neoplasms (benign/malignant, location, metastasis/secondary, status) • Obesity/Morbid Obesity (BMI >40 or BMI >35+associated complication of…) • Peripheral Vascular Disease (occlusion%, site/location, type claud., due to, secondary to)• Pneumonia (suspected type, MRSA, gram negative, aspiration, fungal) • Pressure Ulcers (location, stage, measurements, current status)• Respiratory Failure (acute, chronic, acute on chronic)• Rheumatoid Arthritis (Hx of/due to/secondary to/associated with, remission, inactive)• Schizophrenia (episode, severity, current/recurrent, hx of, with/without psychotic symptoms, type)• Sepsis (underlying infection, related organ failure, septic shock)• Sick Sinus Syndrome (sinoatrial block, sinus arrest, brady-tachycardia, current/hx of)• Vertebral Fractures (initial, subsequent, sequela, type: traumatic, pathological)

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Hospitalist HCC Tip Card

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In-patient Tip Card• HCC In-Patient General List:• Abuse/Dependence (alcohol/cannabis/opioid) • Atrial Fibrillation (paroxysmal/persistent/chronic) • Cardiomyopathy (ischemic/non-ischemic, dilated/hypertrophic)• Cerebrovascular accident CVA (ischemic, hemorrhagic, thrombotic, embolic)• Chronic Kidney Disease (stage I-V/ESRD, etiology, on dialysis)• Acute Kidney Failure (KDIGO criteria, ATN)• Chronic Obstructive Pulmonary Disease (emphysema, chronic bronchitis)• DVT/PE (acute, chronic, recurrent, current, history of, date when, location)• Diabetes Mellitus (type, stable, secondary complications of)• Heart Failure (acute, chronic, acute on chronic, systolic, diastolic, combined, etiology if known)• Depression (major/bipolar, paranoid disorders, mild/moderate, /severe, part/full remission)• Malnutrition/protein-calorie malnutrition (mild, moderate, severe)

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In-patient Tip Card• HCC In-Patient General List:• Myocardial Infarction (STEMI/NSTEMI, dates, current/recurrent) • Neoplasms (benign/malignant, location, metastasis/secondary, status) • Obesity/Morbid Obesity (BMI >40 or BMI >35+associated complication of…) • Peripheral Vascular Disease (occlusion%, site/location, type claud., due to, secondary to)• Pneumonia (suspected type, MRSA, gram negative, aspiration, fungal) • Pressure Ulcers (location, stage, measurements, current status)• Respiratory Failure (acute, chronic, acute on chronic)• Rheumatoid Arthritis (Hx of/due to/secondary to/associated with, remission, inactive)• Schizophrenia (episode, severity, current/recurrent, hx of, with/without psychotic symptoms, type)• Sepsis (underlying infection, related organ failure, septic shock)• Sick Sinus Syndrome (sinoatrial block, sinus arrest, brady-tachycardia, current/hx of)• Vertebral Fractures (initial, subsequent, sequela, type: traumatic, pathological)

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Commonly Missed Chronic Conditions

AmputationsRespiratory failureRheumatoid ArthritisAtherosclerosis or ectasia or aortaAlcohol & Drug Dependency (even in

remission)Morbid Obesity (BMI>40)

Organ TransplantsMalnutritionCHFOstomyChronic psychiatric diagnosisCOPDAneurysm

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In-Patient Comparison 74 year old female presents with right hip fracture which requires right total hip arthroplasty. Nutritional consult is requested by nursing staff who noted patient’s BMI was 16.2. Patient is discharged to SNF with Ensure between meals.

Original DRG 470

RW 2.0816

GMLOS 2.8 days

74 year old female presents with right hip fracture which requires right total hip arthroplasty. Nutritional consult is requested by nursing staff who noted patient’s BMI was 16.2. Registered Dietician assessment notes patient with decreased po intake of < 75% of estimated energy requirement or >1 month and an unintentional weight loss of >5% in one month. Registered Dietician’s assessment is consistent with severe protein calorie malnutrition. Attending physician is queried and agrees with RD’s assessment. Patient is discharged to SNF with Ensure between meals.

New DRG 469

RW 3.2962

Impact 1.2146

GMLOS 5.9 days change + 3.1 days

Added HCC 21 weight 0.7130

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OP Comparison

Patient admitted to observation bed for treatment of non-specified foot ulcer. Query posed to the physician to determine if foot ulcer was related to diabetes (PMH), unrelated to diabetes, other, or unable to determine.

• Original Relative score-diabetes w/o complication 0.160• Relative score after query-diabetes w/chronic complication 0.441• Change in ratio +0.281• Capitation rate ($800 PMPM) X change in ratio $224.00• Relative increase in payment/beneficiary 2019 $2688.00

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Ambulatory Comparison

Annual Wellness Visit76 YO Female No HCC Conditions• Demographics = 0.317• No HCC Chronic Conditions Coded

= 0.00• Total Risk Score = 0.317• Estimated Annual Payment• $2,536

Annual Wellness Visit76 YO Female Nonspecific Coding & Documentation• Demographics = 0.317• Diabetes= 0.118• Unspecified Stage CKD = 0.00• CHF = 0.368• Obesity,unspecified =0.00• Total Risk Score = 0.803• Estimated Annual Payment• $6,424

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Ambulatory Comparison

76 YO Female Documentation & Coding w/Specificity• Demographics = 0.317• Diabetes w/renal complication = 0.368• CKD Stage IV = 0.224• Chronic Systolic CHF = 0.368• DM/Renal/CHF Interaction code = 0.758• Morbid Obesity= 0.273• Total Risk Score = 2.446• Estimated Annual Payment• $20,005

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Polling Question:Does your facility include coding and CDI as part of their committees?

Re-admission Rates

• Don’t forget to document “Z codes”• Social determinants of health including:

• Non-compliance• Substance abuse

• Other “Z” codes• Z51.5-Encounter for palliative care Z• Z56*-Problems r/t employment and unemployment• Z59*-Problems r/t housing and economic circumstances

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Mortalities

• 30 day post discharge • Index admission

• Pneumonia• AMI• Heart failure• Sepsis• CVA ischemic• COPD

• In-patient Mortalities

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ED Outpatient

• Strategy for developing a starting point• Establish baseline

• Start small• Floyd Memorial

• Meeting with key people to discuss• ED physician• ED manager• CDI staff• CDI Director/Manager/Coordinator• CDI Auditor/Educator• Case management • Quality

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CDI for Inpatient Admission from ER

• Benefits for Medical Necessity• Timely query for the most accurate principle diagnosis• Ensure the documentation is consistent from the ED to the admission• Accurate GLMLOS and status from the time of admission

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Current Status of OP CDI

• Observation admission• Review Observation admits

• Ortho total joints• Heart caths

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Current Status Ambulatory CDI

• Pilot physician practices chosen• Software developed--not implemented

• Physician education• Recruiting for ambulatory CDI Director

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Take-A-Ways

• HCC diagnoses directly affect capitated payments to a health plan for its Medicare Advantage members

• For providers, HCC diagnoses are used to risk-adjust quality and cost measures that can affect payment

• Remember HCCs, CCs and MCCs overlap which affect the RAF scores for the calendar year

• Start small and be prepared to grow

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CarylLiptak@bhsi.comLori.Ganote@bhsi.com

Thank You!

Questions?