psi 90: the impact of clinical documentation improvement...
TRANSCRIPT
PSI 90: the Impact of Clinical Documentation Improvement and Coding on Organizational
Financial Performance Shannon Newell, RHIA, CCS, AHIMA Approve ICD-10
Trainer
Learning Objectives
At the end of this presentation, participants will be able to:
• Appreciate the impact of the PSI 90 composite on hospital reimbursement
under the Hospital Acquired Condition Reduction Program and the Hospital
Value Based Purchasing Program
• Understand PSI 90 measure specifications and risk adjustment methodology
• Explain the impact that coding and clinical documentation improvement can
have on PSI 90 performance
• Identify common coding and clinical documentation vulnerabilities for one of
the PSIs in the composite - PSI 15
• Initiate engagement of the coding and clinical documentation improvement
program in PSI 90 performance improvement efforts
CDI Program Perspective
• Inclusions
• Exclusions
• Risk adjustment
Measure Performance
Drivers
• Coding classification system
• Coding guidelines
• Documentation requirements
• Clinical definitions
Vulnerabilities
PSI Background
• Developed in 2003 by the Agency for Health Care Research & Quality
(AHRQ)
– Part of the US Department of Health & Human Services
– Research on healthcare quality, costs, outcomes, access, patient safety
5
http://www.qualityindicators.ahrq.gov/Default.aspx
PSI Background
• Indicators of quality which suggest the need for further investigation
6
PSI Overview
• Resulting PSIs
7
Available PSIs
• A weighted composite of 11 Patient Safety Indicators
• Use of a composite: – Increases statistical precision due to increased sample size
– Supports issue of competing priorities where more than one
component measure may be important
– Assists consumers select healthcare, provider allocate resources, payers
assess performance
8
AHRQ PSI #90 Measure
3 Pressure ulcer 11 Postoperative respiratory failure
6 Iatrogenic pneumothorax 12 Peri-op PE or DVT
7 CLABSI 13 Post-op sepsis
8 Post-op hip fracture 14 Post-op wound dehiscence
9 Peri-op hemorrhage/hematoma 15 Accidental puncture/laceration
10 Postop physiologic & metabolic derangement
PSI 90 Overview
• Payer assessment of provider performance
• CMS adoption into the Inpatient Quality Reporting Program (IQRP) – Public reporting on CMS Hospital Compare
9
PSI Payer Utilization
• CMS inclusion in two pay for performance (P4P) programs
– FY 2013 – Hospital Value Based Purchasing Program (HVBP)
– FY 2015 – Hospital Acquired Condition Reduction Program (HACRP)
• Financial impact:
10
PSI 90 & CMS P4P
HRRP = Hospital Readmission Reduction Program
• PSI 90 currently assigned to the Outcomes Domain
• FY 2017 domain revisions - PSI 90 will move to Safety Domain
11
10%
25%
40%
25%
0% 10% 20% 30% 40% 50% 60% 70% 80%
Cinical Process of Care
Patient Experience of Care
Outcomes
Efficiency
HVBP Domains FY 2013 - 2016
FY 2016 FY 2015 FY 2014 FY 2013
HVBP Domains & Weights
12
HVBP Domains & Weights (cont)
FY 2016IPPS Proposed Rule - in FY2018: 1) Eliminate subdomain “Clinical Care – Process” 2) Eliminate all process measures except PC-01 which will move to “Safety Domain”
30%
20%
25%
25%
25%
25%
25%
25%
0% 5% 10% 15% 20% 25% 30% 35%
Clinical Care
Safety
Efficiency & Cost Reduction
Outcome & Care Coordination
HVBP Domains FY 2017
FY 2018 (Proposed) FY 2017 (Finalized)
FY 2015
Outcomes Domain
FY 2017
Safety Domain
13
Measure (3> measures for Domain Score)
PSI 90
CLABSI
CAUTI
SSI – Colon, Abd Hysterectomy
C. difficile
MRSA
Measure (2> measures for Domain Score)
PSI 90
MORT-30-AMI
MORT-30-HF
MORT-30-PN
CLABSI
FY 2018 –
Add PC-1 Elective Delivery
HVBP Domains & Weights (cont)
• PSI 90 comprises Domain I
• Note the decline in Domain I weight in upcoming years
14
35%
25%
15%
65%
75%
85%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90%
FY 2015
FY 2016
FY 2018
HACRP
HAI (DII) PSI 90 (D1)
HACRP Domains & Weights
• Compares performance scores
with point system
– Other hospitals (achievement)
– Itself (improvement)
HACRP
• Ranks performance against other
hospitals – scored using deciles
HVBP
15
CMS P4P Variances Scoring
• HACRP Performance Period
• HVBP Performance Periods
16
Baseline Period Performance Period
FY 2015 10/15/2010 - 06/30/2011 10/15/2012 – 06/30/2013
FY 2016 10/15/2010 – 06/30/2011 10/15/2012 – 06/30/2014
FY 2017 10/01/2010 – 06/30/2012 10/01/2013 – 06/30/2015
FY 2018* 07/01/2010 – 06/30/2012 07/01/2014 – 06/30/2016
FY 2019 07/01/2011 – 06/30/2013 07/01/2015 – 06/30/2017
FY 2020 07/01/2012 – 06/30/2014 07/01/2016 – 06/30/2018
Performance Period
FY 2015 07/01/2011 – 06/30/2013
FY 2016 07/01/2012 – 06/30/2014
FY 2017* July 1, 2013 – June 30, 2015
CMS P4P Variances Time Periods
*FY2016IPPS Proposed Rule
17
• Different versions
• Impact
– Measure specifications
– Risk adjustment variables
– Risk adjustment coefficients
– Performance comparisons
• Across programs
• Across years
– Composite weighting
• Key variances
– # of diagnoses used
– PSI composite weighting
CMS P4P Variances PSI Versions
• Different versions impact how PSI performance is weighted
18
2.3
%
7.1
%
6.5
%
0.1
%
25
.8%
7.4
%
1.7
%
49
.2%
-10%
0%
10%
20%
30%
40%
50%
3 6 7 8 12 13 14 15
PSI Composite Weight
HACRP HVBP
CMS P4P Variances PSI Versions (cont)
• Excludes 3 of the PSIs in the AHRQ PSI 90 Composite*
– 9 Peri-operative hemorrhage/hematoma
– 10 Post-op physiologic & metabolic derangement
– 11 Post-op respiratory failure
• Refines statistical methodologies (“smoothed rate”) to account for
Medicare population characteristics
19
CMS PSI #90 Measure
3 Pressure ulcer 12 Peri-op PE or DVT
6 Iatrogenic pneumothorax 13 Post-op sepsis
7 CLABSI 14 Post-op wound dehiscence
8 Post-op hip fracture 15 Accidental puncture/laceration
CMS Modifications to AHRQ PSI 90
*PSI 90 is currently undergoing NQF maintenance review
• AHRQ
– Healthcare Cost Utilization Program (HCUP) databases
– State data
– All payer population
• CMS
– Final action paid claims from the inpatient Health Accounts Joint
Information (HAJI) files
– Medicare part A claims data
– Traditional Medicare population
• Includes claims submitted for discharges with dates in the cited discharge
periods
20
Data Sources
The Impact of Documentation & Coding
• Code assignment has a significant impact on claims based measures
• Code assignment has some impact of some chart abstracted measures
22
The Impact of Code Assignment
• Reimbursement
• Reputation
• Performance Improvement
23
MS-DRG 690 Urinary tract infection wo complication
MS-DRG 871 Sepsis major complication
UTI Bacteremia Hypotension Hypoxemia Cachexia
6 day LOS Expired
Sepsis due to UTI Septic shock
6 day LOS Expired
1 2
Impact- MSDRGs
24
MS-DRG 690 Urinary tract infection wo complication
SOI score - 3 ROM score - 3
MS-DRG 871 Sepsis w major complication
SOI score – 4 ROM score - 4
UTI Bacteremia Hypotension Hypoxemia Cachexia
6 day LOS Expired
Sepsis due to UTI Septic shock Resp failure, acute Malnutrition
6 day LOS Expired
2 1
Impact – APR-DRGs Severity of Illness (SOI), Risk of Mortality (ROM)
• Documentation and code impact: inclusions, exclusions, risk adjustment
25
Measure Impact PSI Example
Includes discharge PSI 3 Pressure Ulcers
Pressure ulcer not present on admission unstageable
Excludes discharge PSI 3 Pressure Ulcers
Any pressure ulcer present on admission
Excludes discharge PSI 7 Central line associated blood stream infections
History of a malignant neoplasm
Excludes discharge PSI 8 Post-op hip fracture
“Pathologic” fracture
Excludes discharge PSI 13
Post-op sepsis
Admission type other than elective
Risk adjustment PSI 15
Accidental puncture/ laceration
“Obesity”, “Pulmonary Hypertension”, “CKD”
Impact- PSI 90
Measure Structure
• Technical Specifications
27
PSI 15 # of Patients with Pressure Ulcer / # Patients in Population
Measure Structure
• PSI 15 – Accidental Puncture / Laceration
28
Numerator = inclusion
Numerator – “Outcome of Interest”
• PSI 15 – Accidental Puncture / Laceration
29
Numerator = inclusion
• Inclusions
Denominator – Population “At Risk”
• PSI 15 – Accidental Puncture / Laceration
30
Numerator = inclusion
• Inclusions
Denominator – Exclusions
Exclusions: • Improve accurate
capture of intended population
• Enhance face validity with clinicians
31
Risk Adjustment Methodology
32
Risk Adjustment Methodology (cont)
• 25 comorbid categories
■ ICD code mapping
■ Same definitions
■ Varied application
■ Varied risk adjustment
impact
■ Must be POA
■ Denominator capture counts
• AHRQ HCUP Comorbidity
Software is used to create the
risk adjustment coefficients
33
Numerator = inclusion
Risk Adjustment Methodology (cont)
• ICD-9-CM code mapping
■ Volume of codes: 1 code (HIV) 255 codes (Lymph)
■ In general: chronic conditions, low specificity (e.g. “CHF”, “anemia”)
34
Numerator = inclusion
Risk Adjustment Methodology (cont)
• Impact can be positive or negative
35
Numerator = inclusion
PSI #3
61%
20%
16%
4%
0%
10%
20%
30%
40%
50%
60%
70%
WGHTLOSS OBESE PERIVASC RENLFAIL
PSI #15
Risk Adjustment Methodology (cont)
36
• Inclusions
Discharge
Discharge
Discharge
Eligible Discharges (Denominator) (Population at risk)
Outcomes of Interest
(Numerator) Risk Adjustment
(Comorbid Conditions)
Summary
37
Summary (cont)
Coding and Documentation Vulnerabilities
39
Numerator = inclusion
PSI #3
Code Review
Coding Classification System: Index and Tabular must be used together
• Coding classification system provides all available codes
• Coding guideline hierarchy
– Classification system
– Official Coding Guidelines (OCG)
– AHA Coding Clinics
• Includes accidental perforation by catheter or other instrument during a
procedure on blood vessel, nerve, organ
• Excludes iatrogenic pneumothorax, dural tears, puncture or laceration by
implanted device intentionally left in operation wound, others
Inclusion – Assignment of Code 998.2 Classification System
40
Inclusion – Assignment of Code 998.2 OCG – Additional Diagnoses
41
Inclusion – Assignment of Code 998.2 OCG - Complications
42 Official Coding Guidelines – Section I-B, I-C
• “Complication” – assign 998.2
Inclusion – Assignment of Code 998.2 AHA Coding Clinic – “Complications”
43
• The physician does not need to document the word “complication”
Inclusion – Assignment of Code 998.2 AHA Coding Clinic – “Tear”
44
Inclusion – Assignment of Code 998.2 AHA Coding Clinic – “Tear”
45
• Dural tears are always coded
– “Always clinically significant due to the potential for CSF leakage”
– Secondary diagnoses reporting criteria – additional monitoring
– Code assignment is NOT 998.2. (Not included in PSI 15)
• “Tear” controlled with hemopad
• Query: Inherent or complication
Inclusion – Assignment of Code 998.2 AHA Coding Clinic – “Tear”
46
• “Serosal injury” with repair in setting of mass adhered at GE junction
• Query: Incidental or complication
Inclusion – Assignment of Code 998.2 AHA Coding Clinic – “Injury”
47
Inclusion – Assignment of Code 998.2 Case by Case Interpretation
48
Procedure Op Note Documentation
Lap converted to open
appendectomy and repair of
bladder injury
“The appendix was ultimately identified and dissected away
from these structures. In the process of doing this and
identifying the abscessed cavity, there was a tremendous
amount of necrotic material overlying the bladder. In debriding
this material, the bladder was entered. It appeared that the
bladder wall was also involved, and a portion of the bladder
wall appeared nonviable. At this point Urology was consulted
for assistance in repairing the bladder.
Lap gastric band removal,
intraoperative endoscopy repair
“The endoscope was then removed and at this point we noticed
a small 1 cm laceration in the inferior medical portion of the
spleen that was actively bleeding; pressure was held on the
site for 10 minutes. An additional Evicel was applied over the
Surgicel until the area was hemostatic.”
Right ankle arthrodesis, right
distal tib-fib arthrodesis, removal
of hardware from right fibula,
removal of hardware right tibia
“During this section due to significant amount of scar tissue her
peroneous brevis tendon was entrapped in scar tissue and
ruptured while it was being released.” “Prior to closure of skin
and subcutaneous tissues we did repair the peroneous brevis
tendon, which was quite easy to accomplish.”
Inclusion – Assignment of Code 998.2 UHC PSI 15 Consensus Document
49
Terminology
Not Complication Complication
• Required • Inherent • Integral • Routinely expected
• Complication • Inadvertent • Unintended • Iatrogenic • Unexpected
• Template – post-op note complication field
• Report so it can be coded, reported, and evaluated
for performance improvement
• Physician documentation
– Non-accidental: inherent/integral/intended, reasons for
– Complication
50
Inclusion – Assignment of Code 998.2 UHC PSI 15 Consensus Document (cont)
• CDS / Coders to query if unclear
– Procedure note terminology / without description of circumstances
– Post op / procedure note documentation conflicts with other documentation
in the medical record
– Indications of a reportable event
• Reportable if required: clinical evaluation, treatment, procedure, length
of stay, increased nursing care or monitoring
• Examples:
– Repair
– Follow-up
– Blood transfusion
– Return to OR
– Consult
– Resulted in damage to / loss of organ / death
Inclusion – Assignment of Code 998.2 Bulletin ACS May, 2014
51
Inclusion – Sequencing of Code 998.2 OCG – Principal Diagnosis Sequencing
52
53
Inclusion – Sequencing of Code 998.2 OCG – Principal Diagnosis Sequencing
Inclusion – Assignment of E Codes OCG – E Code Assignment
54
Risk Adjustment Diagnoses OCG – Additional Diagnoses
55
• Any healthcare provider
– Physicians
– Any qualified healthcare practioner legally accountable for establishing
the patient’s diagnosis
• Current encounter
– Entire medical record
• When conflict across providers, query attending physician
– Conflict? “Bacteremia” “Sepsis” – Conflict? Attending physician did not document
56
Source: CMS Medicare Learning Network (MLN) Matters -SE 1121
Risk Adjustment Diagnoses OCG – Documentation Sources
• Documented “at the time of discharge”
• Uncertain Diagnosis Exceptions
– HIV
– Influenza due to some viruses – avian, novel, H1N1, influenza A
57
Risk Adjustment Diagnoses OCG – Uncertain Diagnoses
• Risk Adjustment does not count comorbid conditions unless POA
58
Risk Adjustment Diagnoses OCG – Present on Admission
• “Chronic conditions such as but not limited to HTN, Parkinson’s disease,
COPD, & diabetes mellitus are chronic systemic diseases that ordinarily
should be coded even in the absence of documented intervention or further
evaluation.”
59
Risk Adjustment Diagnoses AHA Coding Clinic – Chronic Conditions
• AHIMA and ACDIS Query Practice Brief 2013
60
Risk Adjustment Diagnoses Query Practice Brief – Clinical Validation
• 4th highest positive impact
• 25 codes
Risk Adjustment Diagnoses CC: RENLFAIL – Key Concepts
61
Numerator = inclusion
61%
20% 16%
4%
0%
10%
20%
30%
40%
50%
60%
70%
WGHTLOSS OBESE PERIVASC RENLFAIL
PSI #15
Key Concepts
• CKD
• “Renal failure”
• Kidney transplant status
• Renal dialysis status
• Highest impact
• 18 codes
Risk Adjustment Diagnoses CC: WGHTLOSS – Key Concepts
62
Numerator = inclusion
61%
20% 16%
4%
0%
10%
20%
30%
40%
50%
60%
70%
WGHTLOSS OBESE PERIVASC RENLFAIL
PSI #15
Key Concepts
• Malnutrition
• Underweight
• Loss of weight
Adults: BMI < 18.5 Children: < 5th %ile
Risk Adjustment - WGHTLOSS Clinical Definitions – Underweight
63
www.cdc.gov/healthyweight/assessing
Risk Adjustment - WGHTLOSS Classification System - Malnutrition
64
• Includes all codes
65
• Includes
─ “CKD <stage”, “chronic renal insufficiency, “Renal failure” ─ Does not include “acute renal failure”
Risk Adjustment Diagnoses - RENLFAIL Classification System - CKD
66
• Does not include “renal insufficiency” unless documented as “chronic”
• Does not include ‘acute renal insufficiency”
Risk Adjustment Diagnoses - RENLFAIL Classification System – Renal Insufficiency
67
Numerator = inclusion
PSI #3
Audit Checklist
CDI Program Engagement
69
• Definition of CDI Program
An organizational system chartered to improve capture of clinical
documentation and ICD code assignment
• Common Organizational Objectives
■ Accurate, optimal reimbursement for provided services
■ Minimal delays in billing due to post-discharge documentation queries
■ Minimal re-bills associated with post-discharge documentation and
associated ICD-code revisions
■ Reduction of denials by payers and other external review organizations
■ Accurate, optimal quality profiles for claims based outcomes
• CDI Program
■ Coding team and processes
■ Clinical documentation specialist team and processes
■ Performance management
CDI Program Overview
70
What Measures? Risk Adjustment?
• Numerous methodologies for quality measures • Each system has its own methodologies • Lack of agreement among the national hospital rating systems • Example: Only 10% of hospitals rated as a high performer by one rating
system were rated as a high performer by other leading national hospital rating systems
http://m.content.healthaffairs.org/content/34/3/423.abstract?sid=6c0faf3e-5fc0-45f1-80ba-5e3c39982828
71
• Risk adjustment will be optimized for PSI 7 (CLABSI) with capture of one diagnosis from each of the following comorbid categories
19%
16%
13% 13%
7% 7% 6%
5% 5% 4%
3%
0%
0%
5%
10%
15%
20%
25%
WGHTLOSS PARA BLDLOSS DRUG OBESE NEURO ANEMDEF RENLFAIL CHF LIVER ARTH VALVE
PSI #7
CDI and CMS P4P
■ Systematic capture of “underweight”
■ Systematic capture of kidney disease acuity and stage
72
E.H.R. Refinement
Falcon Consulting
• Success under CMS P4P requires clear organizational priorities, a data
driven focus, and strengthening of the documentation infrastructure
73
CDI Program Evolution
Coding & Query Process
Provider Education
Performance Management
Documentation Infrastructure
CDI Program
• Develop CDI team quality lead role
• Identify organizational priorities
• Educate the CDI team on measure drivers
• Identify (and validate) data quality vulnerabilities
• Develop and implement actions to strengthen performance – CDI Team review processes
– Pre-bill validation review
– Provider education
– E.H.R. refinements
• Monitor performance improvement – Refine CDI Program Performance Metrics
– Participate on quality teams
Engagement Checklist
74
• Table 3 - PSI performance breakout
– “Better performance” = Smoothed Rate < National Risk Adjusted Rate
– Consider composite weight, volumes
– Annual ranking by decile continual improvement
HACRP Hospital Specific Report
75
High Leverage Opportunities Inclusions & Exclusions
76
Inclusion/Exclusion Impacting 2> PSIs
PSI
3 6 7 8 12 13 14 15
POA Status
Length of Stay (dates)
Cancer Dx (includes personal hx)
Immunocompromised State
Procedure Dates
E Codes
Point of Origin* * * * *
* Impacts risk adjustment per Parameter Estimates
Summary
• Documentation and code assignment impact claims based measure
performance through accurate and optimal inclusion, exclusion, and risk
adjustment of discharges
• CMS P4P initiatives expand the financial impact of assigned codes
• Evolution of today’s CDI programs is required to address these new challenges
Thank You – Questions?