the big wide world of mds data · measure quality metrics 2. public reporting of quality measures...

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©Pathway Health 2013©Pathway Health 2013

The Big Wide World of MDS data

Karolee Alexander, RN, RAC-CTDirector of Clinical and Reimbursement Consulting

WHO SEES AND USES THE INFORMATION?


1. Identify the many uses of MDS data2. Describe the interrelated nature of MDS

data use3. Define three strategies for MDS coding

excellence

Learning Objectives:


Let’s go back……..

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Quality Reporting

Reimbursement

Clinical Assessment and Care Planning


• Government Accountability Office

– Medicare Program is at high risk for fraud, waste, and abuse

• Office of Inspector General– In 2012, 25% of SNF claims

were billed in error

• Centers for Medicare and Medicaid Services

– In 2013, SNFs were required to have a compliance program

Government Alignment

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Medicare Growth

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©Pathway Health 2013

Medicaid Spending

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• Delivery system reform– Paying for quality care

• New ways to pay

• Alternative Payment models

– Improving health care• Hospital readmissions reduction

– Unlocking data

• Cracking down on fraud

Affordable Care Act 2010

Transition to risk based payment

9Source: CliftonLarsonAllen 2015

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CMS INNOVATION

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Innovation Center A new engine for revitalizing and sustaining the Medicare, Medicaid and CHIP programs and ultimately to help to improve the healthcare system for all Americans.• Flexibility and resources• Test innovative care models• Test innovative payments models

http://innovations.cms.gov

Accountable Care Organizations


Accountable Care Organizations• Shared Savings

• Shared Risk

Models

Pioneer Model

Next Generation ACO

Investment Model


Models

https://innovation.cms.gov/

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Models



• Acute myocardial infarction Read MoreAmputation Read MoreAtherosclerosis Read MoreAutomatic implantable cardiac defibrillator generator or lead Read MoreBack and neck except spinal fusion Read MoreCardiac arrhythmia Read MoreCardiac defibrillator Read MoreCardiac valve Read MoreCellulitis Read MoreCervical spinal fusion Read MoreChest pain Read MoreChronic obstructive pulmonary disease, bronchitis/asthma Read MoreCombined anterior posterior spinal fusion Read MoreComplex non-Cervical spinal fusion Read MoreCongestive heart failure Read MoreCoronary artery bypass graft surgery Read MoreDiabetes Read MoreEsophagitis, gastroenteritis and other digestive disorders Read MoreDouble joint replacement of the lower extremity Read MoreFractures femur and hip/pelvis Read MoreGastrointestinal hemorrhage Read MoreGastrointestinal obstruction Read More

Hip and femur procedures except major joint Read More

Lower extremity and humerus procedure except hip, foot, femur Read More

• Major bowel Read MoreMajor cardiovascular procedure Read MoreMajor joint replacement of the lower extremity Read MoreMajor joint replacement of upper extremity Read MoreMedical non-infectious orthopedic Read MoreMedical peripheral vascular disorders Read MoreNutritional and metabolic disorders Read MoreOther knee procedures Read MoreOther respiratory Read MoreOther vascular surgery Read MorePacemaker Read MorePacemaker Device replacement or revision Read MorePercutaneous coronary intervention Read MoreRed blood cell disorders Read MoreRemoval of orthopedic devices Read MoreRenal failure Revision of the hip or knee Read MoreSepsis Read MoreSimple pneumonia and respiratory infections Read MoreSpinal fusion (non-Cervical) Read MoreStroke Read MoreSyncope and collapse Read MoreTransient ischemia Read MoreUrinary tract infection Read More

Bundle Payment Care Initiative




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IMPACT Act 2014

1.Standardize assessments to measure quality metrics

2. Public reporting of quality measures

3. Quality measures provided to consumers when patient transitions to PAC

4. HHS and MedPAC conduct studies linking quality and payment

5. CMS received funding to measure PBJ


• Protecting Access to Medicare Act of 2014 (PAMA) – establishing a Skilled Nursing Facility

Value-Based Purchasing (SNF VBP) Program beginning with FY 2019 under which value-based incentive payments are made to SNFs in a fiscal year based on performance.

PAMA Act 2014


• Updates to payments for PAC providers• Requires GAO to examine how to

implement quality measures for Medicaid payments

• Investigate integration of Medicare Advantage plans into Alternative Payment Models

MACRA 2015

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National Quality Strategy

part of ACA 2010


CMS Quality Strategy


CMS MOVES TOWARD THE FUTURE

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Data Sharing Across PAC


MDS IS THE SOURCE


MDS

Medicare

Alternative Payment Models

Quality Measures

5 Star Report

Survey

Focus Survey

Care Plan

Interrelated

CAAs

CASPER reports

CMS 802

PEPPER reports

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ASSESSMENT AND CARE PLANNING

MDS

Medicare


Quality Measures

5 Star Report

Survey

Focus Survey

Care Plan

CAAs

CASPER reports

CMS 802

PEPPER reports


IDT Assessments

MDS

CAAsCare Plan

Implementation

ASSESSMENT AND CARE PLANNING


• Timely–ARD & Completion Date

• Complete–CAAs

• Accurate• Consistency

–Supporting documentation

Tactics for Success: Assessments

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• Plan–Communicate

• Schedule–Adjust as needed

• Abstract data–Clarify –Code per RAI manual

• Care Plan

Tactics for Success: MDS


• Critical thinking• USE THE WORKSHEET• Proceed to care plan with direction

Tactics for Success: CAAs


• Use the data that was collected• Person Centered

–Describe how the issue affects this specific person

• Reasonable goal• Update interventions

Tactics for Success: Care Plans

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MDS

MedicareAlternative Payment Models

Quality Measures

5 Star Report

Survey

Focus Survey

Care Plan

REIMBURSEMENT

CAAs

CASPER reports

CMS 802

PEPPER reports



Data gathering and review!!!

HHS ‐ Establish SNF all‐condition hospital readmission measure PRIOR to 10/1/15

HHS ‐ Establish SNF all‐condition risk‐adjusted preventable hospital readmission measure

HHS ‐ Begin providing “confidential feedback” to SNFs quarterly

PUBLIC REPORTING ‐ Readmission Measure on Nursing Home Compare Site

Medicare reimbursement rates for SNF will be based partially on their performance scores beginning on October 1, 2018.

SNF Medicare A Value Based Purchasing

10/1/15

10/1/16

10/1/18

10/1/14

10/1/17

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Potentially preventable hospitalizations

Medicare & Medicaid Research review 2014: Volume 4, Number 1



New Quality Measure - VBP

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Already in your CASPER reports


• Stays that started over a 12-month period.

• Data are updated every six months (April and October of each year),

• Lag time of nine months (i.e., the

• data posted in April will include stays that started 9-21 months ago).

INCLUDES

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• Acute Illness• Complications of care• Procedures performed DURING an acute

illness admission not likely to be planned• Observation stays regardless of diagnosis

UNPLANNED

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Pre‐specified list:• Bone marrow, kidney or

other transplant• Maintenance

chemotherapy and rehabilitation

• Pregnancy associated diagnoses and procedures

• “Psychiatric hospitals or units are also classified as planned readmissions”

Centers for Medicare & Medicaid Services Planned Readmission Algorithm ‐‐ Version 2.1


• Stay begins – resident enters a nursing facility

• based on the entry/reentry date from the MDS

• Stay ends• person leaves the nursing home

– based on discharge date from the MDS, regardless of whether the discharge was planned or the resident was anticipated to return to the facility.

Definition

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• Enrolled in a Medicare Advantage plan for any part of the stay OR

• Was not enrolled in both Medicare Part A and B for any part of their stay

• Resident has Hospice claims that overlap with the nursing home stay

EXCLUSIONS

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MDS COVARIATES

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Category MDS item

Other

Functional Status

First assessment was Significant Change in Status

EatingWalk in room or corridorWandering2 person support for ADLsCognitive status impaired or not codedAcute change mental statusRarely make self understoodFall in last month or last 2‐6 monthsRejected care 4‐7 daysCoughing or choking during meals


MDS COVARIATES

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Category MDS items

Clinical conditions End stage prognosisVenous/arterial ulcerInfection of footDiabetic foot ulcerInternal bleedingDehydratedDaily painSurgical woundTotal bowel incontinenceSOB with exertion, when sitting at rest or when lying flat


MDS COVARIATES

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Category MDS items

Clinical Treatments Parenteral/IV feedingsFeeding tubeInsulinDialysisOstomy careOxygenChemo for cancerRadiation for cancerTracheostomyIV medsVentilator or respiratorTransfusionAntibiotic

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MDS COVARIATES

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Category MDS items

Clinical Diagnoses AnemiaSepticemiaDiabetesRespiratory failureViral hepatitisHeart FailureAlzheimer’s diseaseNon‐Alzheimer’s dementiaCancerPneumoniaUTISeizure disorder Ulcerative colitisWound infection other than foot



Vaccines

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• Have a quality improvement process to monitor and evaluate re-hospitalizations for all conditions.

• Use case review and root cause analysis to identify opportunities to improve clinical skills and processes.

• Review diagnostic services and urgent pharmacy availability to support care of residents in the facility.

• Review your process for end-of-life care discussions and support for residents and families

Strategies for Success


Refinement of Readmission Measure


• Claims based• Risk adjusted based on claims “Admitting

Diagnosis” at the time of rehospitalization• Numerator –risk adjusted estimate of the

number of Medicare Part A unplanned potentially preventable readmissions within 30 days for discharges from acute hospital stay to the SNF

• Denominator – Number of Medicare Part A unplanned preventable readmissions that would be expected for the SNF population at the average facility

Preventable Readmission Measure

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October 2016: “Potentially preventable” adjusted rate October 2017: Public reporting of SNF readmissions October 2018: Ranked score provided to SNFs

2% withhold of SNF payments 50‐70% of the withhold will go to incentive

payments to SNFs 30‐50% of the withhold will go to

Medicare for savings Incentive/ penalty goes live

40% of SNFs nationally will receive a penalty Estimated to save Medicare $2B over next 10 years

SNF Readmission Penalty Timeline


External Audits

https://www.ahcancal.org/facility_operations/MedicareRAC/Pages/RACContractors.aspx


RAC Quarterly Update

https://www.cms.gov/Research‐Statistics‐Data‐and‐Systems/Monitoring‐Programs/Medicare‐FFS‐Compliance‐Programs/Recovery‐Audit‐Program/Downloads/Medicare‐FFS‐Recovery‐Audit‐Program‐1st‐Qtr‐2016.pdf

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• Provider Compliance Tips posted by CMS• Provider Relations Coordinator established• RAC must maintain an overturn rate of <

10% at first level of appeal • RAC auditors are required to maintain an

accuracy rating of at least 95%• Look-back period limited to 6 months from

date f service• Fall 2015 Provider Satisfaction Survey

RAC Program Enhancements


• PEPPER –Program for Evaluating Payment Patterns Electronic Report

https://www.pepperresources.org/

PEPPER


Triple Check Tool

https://www.pepperresources.org/Training‐Resources/Skilled‐Nursing‐Facilities

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• Understand the Alternative Payment Model activity in your area https://innovation.cms.gov/

• Identify the facility’s strengths: – clinical competence and capacity– Length of stay for conditions

– Total cost of care– Customer satisfaction

• Use data to demonstrate high quality, especially if costs are high

Tactics for Success


• Assess your organization’s readiness for change.

http://www.hrsa.gov/quality/toolbox/methodology/readinessassessment/

• Be educated about upcoming changes and stay abreast of information as it happens.

https://public.govdelivery.com/accounts/USCMS/subscriber/new?pop=t&topic_id=USCMS_7819

Tactics for Success


• Re-assess you documentation systems to support new data collection.

• Implement an internal MDS coding monitoring system to ensure data accuracy.– Use PEPPER report and tools

Tactics for Success

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MDS

Medicare


Quality Measures

5 Star Report

Survey

Focus Survey

Care Plan

QUALITY REPORTING

CAAs

CASPER reports

CMS 802

PEPPER reports


• http://www.medicare.gov/NHCompare• Each nursing home participating in Medicare

and/or Medicare is a assigned an overall rating between one and five stars

– 5 Stars = Much above average*

– 1 Star = Much below average*

* Compared to other nursing homes in the state

Nursing Home Compare

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• 1 – 5 stars assigned to each domain

Health Inspections

Staffing

Quality Measures

Three Domains

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5 Star Ratings

http://kff.org/report‐section/reading‐the‐stars‐nursing‐home‐quality‐star‐ratings‐nationally‐and‐by‐state‐issue‐brief/


Current 5 STAR QMsQM Stay group

% residents with increased dependence in ADLs Long

% high risk residents with pressure ulcers Long

% residents with indwelling catheter Long

% residents with physical restraint Long

% residents with UTI Long

% residents with self report of moderate to severe pain Long

% residents with one or more falls with serious injury Long

% residents on antipsychotic medication Long

% residents with new or worse pressure ulcer Short

% residents with self‐report of moderate to severe pain Short

% residents newly on antipsychotic medication Short


New QMs

Abt Associates report, CMS Open Door Forum March 3, 2016

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• Target period - The span of time that defines the QM reporting period (e.g., a calendar quarter).

• Episode. A period of time spanning one or more stays. An episode begins with an admission (defined below) and ends with either (a) a discharge, or (b) the end of the target period, whichever comes first.

• Cumulative days in facility (CDIF). The total number of days within an episode during which the resident was in the facility.

QM DEFINTIONS

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• Short stay - An episode with CDIF less than or equal to 100 days as of the end of the target period.

• Long stay - An episode with CDIF greater than or equal to 101 days as of the end of the target period.

• Look back scan - Scan all assessments within the current episode.

• Special rules for influenza vaccination measures - Influenza vaccination measures are calculated only once per year

QM DEFINTIONS


• Target date - The event date for an MDS record, defined as follows: – For an entry record (A0310F = [01]), the

target date is equal to the entry date (A1600). – For a discharge record (A0310F = [10, 11]) or

death-in-facility record (A0310F = [12]), the target date is equal to the discharge date (A2000).

• For all other records, the target date is equal to the assessment reference date (A2300).

QM DEFINTIONS


• Use Medicare Part A claims to identify residents

• Some claims information used for risk adjustment

• Only short-stay Medicare Part A• MDS data is used for risk adjustment

Claims Based Measures

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Percentage Of Short-stay Residents Discharged To The Community• MDS is used to identify community

discharges• Claims and MDS for risk adjustment• Claims used to determine if discharge was

successful– No hospitalizations, readmission to nursing

home or death within 100 days after admission to the nursing facility and 30 days after discharge from nursing home

CLAIMS BASED


Percentage Of Short Stay Residents Who Had An Outpatient Emergency Department VisitPart B claims to identify ED visitsClaims and MDS for risk adjustmentTime frame -30 days after admission to a SNF following an inpatient hospital stay.

CLAIMS BASED


One new assessment-based quality measure, and three claims-based measures for inclusion in the SNF QRP.• Assessment-based measure for the FY

2020 payment determination:– Drug Regimen Review Conducted with Follow-

Up for Identified Issues.

FUTURE MEASURES

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• Claims-based measures for the FY 2018 payment determination and subsequent years:– Discharge to Community – Post Acute Care

(PAC) SNF QRP;– Medicare Spending Per Beneficiary (MSPB) –

PAC SNF QRP; and– Potentially Preventable 30 Day Post-Discharge

Readmission Measure for SNFs.

FUTURE MEASURES


• Use a pre-bill review process – Source information must be correct

• MDS coding accurate

• Claims information accurate

• Focus on successful discharges– Identify the resident’s discharge goals early and

have frequent communication about progress.– Have a system for communicating the post-

discharge care needs and plans.– Consider follow-up contact in the community.

Strategies for Success


SNF Quality Reporting Program

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Data Uniformity

The IMPACT Act of 2014 and Data Standardization


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STANDARIZATION


Three Measures for October 1, 2016

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New or worsened pressure ulcers


Falls with Major Injuries


Functional Assessment

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• ONLY FOR MEDICARE PART A stays• New MDS - Medicare PPS Discharge MDS.• New MDS Section – Section GG

– Section GG only for Medicare 5-day and Medicare PPS Discharge MDS.

– Included when MDSs care combined– Required coding in all Section GG items – no

dashes– Requires a Discharge goal code for at least one

Section GG item on Medicare 5-day MDS.



Section GG and Medicare A Discharge


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Section GG coding different from Section G coding


Section G Section GG

For All MDSs Only for Medicare 5‐day and Medicare Discharge MDSs

Code based on most dependent functionand most staff assistance in the 7 day observation period

Code based on USUAL function in the first 3 days and last 3 days of Medicare stay. Exclude most dependent and most independent performance.

Uses the “rule of three” to analyze documentation

Professional assessment based on direct observation, interviews of resident, family and staff and review of medical record.

Goal for discharge function not coded Goal for discharge function coded on 5‐day MDS

Affects reimbursement 80% of Medicare MDSs must have Section GG coded or no Annual Payment Update


Section G ‐ Most Dependent Section GG – Usual performance

0 ‐ INDEPENDENT 06 ‐ INDEPENDENT

1 ‐ SUPERVISION 05 ‐ SET UP OR CLEAN UP ASSIST

2 ‐ LIMITED ASSIST 04 ‐ SUPERVISION OR TOUCHING ASSIST

3 ‐ EXTENSIVE ASSIST 03 ‐ PARTIAL/MODERATE ASSIST

4 ‐ TOTAL DEPENDENCE 02 ‐ SUBSTANTIAL/MAXIMAL ASSIST

7 ‐ OCCURRED ONCE OR TWICE 01 ‐ DEPENDENT OR 2 OR MORE HELPERS

8 ‐ DID NOT OCCUR 07 ‐ RESIDENT REFUSED

09 ‐ NOT APPLICABLE

88 ‐ NOT ATTEMPTED DUE TO MEDICAL CONDITION OR SAFETY CONCERN

Compare/Contrast

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• Access the reports now and examine your scores

• Plan for extensive education for MDS Coordinators, IDT team and CNAs.

• Contact your software vendor about plans for supporting documentation for CNAs and Nurse Assessment.

• Determine the number of Medicare Part A patients who stay more than one day after Medicare coverage ends.

Tactics for Success


• Know and understand the Quality Measure data

• Ensure MDS coding accuracy• Download and review 5 Star report and

Federal Quality Measures.• Examine MDs and supporting

documentation for included residents.• Fix resident level issues identified

Tactics for Success


• Identify trends in systems that support documentation and coding– Root Cause Analysis – Charter a Performance Improvement Project– Be sure to include the people who do the

process

– Trial an improvement in a small scale– Re-evaluate and Revise until you achieve the

desired outcome– Expand the improvement

Tactics for Success

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Will There Be MDS 4.0? RUGs V?

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MDS

Medicare


Quality Measures

5 Star Report

Survey

Focus Survey

Care Plan

REGULATORY COMPLIANCE

CAAs

CASPER reports

CMS 802

PEPPER reports


Off-site Preparation - Quality Measure reports• Facility characteristics• Facility QM report• Resident Level QM reports

– Identify residents pre-selected by QM– Flag sentinel events– Flagged at 90th percentile– Unflagged at 75th percentile

Traditional Survey

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• Ask the facility to complete the Roster/Sample Matrix form (CMS 802) by the end of the initial tour– Can update for 24 hours

• Compare it to the findings from the tour to determine if there is a reason to substitute another resident

Traditional Survey


Off-site preparation –reports• Casper 3 –Facility History Profile and

CASPER 4 –information provided by the facility on CMS 672 during last survey

• Download MDS data• ASE-Q selects a random sample for Stage

1• Use Roster/Sample Matrix to highlight

concerns and list potential residents pre-selected

QIS Survey


• In one report, the OIG stated, “SNFs reported inaccurate information, which was not supported or consistent with the medical record, on at least one MDS item for 47 percent of claims” reviewed in the study.

MDS Focus Survey

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MDS Focused Survey combined with a review of nursing home staffing

– Intended to strengthen the Nursing Home Five-Star Quality Rating System

– Survey worksheets revised– Deficiencies were identified in 24/25 trial

surveys and resulted in relevant citations and enforcement actions.

– Deficiencies categorized as “Complaint Survey” for 5 Star report purposes.

MDS Focus Survey

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Pilot Findings • Deficiencies in 24 of 25 trial surveys• 25% disagreement rate for falls with

injury• 18% disagreement rate for pressure ulcer• 17% disagreement rate for restraints• 15% disagreement rate for late loss ADLs

Focus MDS & Staffing Survey


1. Identification of a Wound Care Nurse (and if he/she is available during survey process), wound team, wound care facility, etc. Who coordinates wound care in the facility? How is wound care tracked?

2. Identification of whom in the facility is responsible for staffing and if they are available to provide information and questions during the survey process.

3. 10 most recently completed MDSs4. List of correction requests submitted, if any

5. List of schedules of people involved in MDs coding

ENTRANCE CONFERENCE

105

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6. All facility Policies and Procedures related to Staffing and scheduling.

a. There are no Federal requirements for having a policy and procedure for staffing, – There are requirements that a center has

certain designated positions ( i.e, DON, Administrator).

– Review each section of the regulation relative to minimal requirements.

– There is a requirement for posting the total number of actual hours worked.

ENTRANCE CONFERENCE

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7. Completed Medicare Medicaid application (Form CMS 671).

a. This must be provided to surveyors within 24 hours of entrance conference.

b. Be certain the individual completing the Form 671 understands how to accurately complete the Form –

how to report staff hours worked in the designated time period.

Read the instructions on the form carefully to capture direct staff as defined by CMS

MDS-Focused Survey Tip Sheet March 20, 2015 AHCA Workgroup comprised of members of Clinical Practice and Survey/Regulatory Committees

ENTRANCE CONFERENCE

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ENTRANCE CONFERENCE

108CMS 2015

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– ARD– Completion– Accuracy– Pressure Ulcers– Falls with Injury– Restraints– ADLs

• Coding that supports QMs > 75th percentile

• Section I as comorbidities for 30-day readmission measure

Tactics for Success

Have an MDS monitoring system in place

Karolee Alexander, RN, RAC‐CTDirector of Clinical and Reimbursement Consulting

Pathway [email protected]


• Medicare-Medicaid Eligible Beneficiaries and Potentially Avoidable Hospitalizations Misha Segal,¹ Eric Rollins,¹ Kevin Hodges,¹ and Michelle Roozeboom², ¹Centers for Medicare & Medicaid Services, ²General Dynamics Information Technology in -Medicare and Medicaid Research Review 2014: Volume 4, Number 1

• CMS Innovation Center: https://innovation.cms.gov/

• Abt Associates report, CMS Open Door Forum March 3, 2016

• Medicare & Medicaid Research review 2014: Volume 4, Number 1

• Quality Measures: https://www.providigm.com/wp-content/uploads/2013/08/Mar14_2014_SNFQualityMeasures_CONTRACTOR.pdf

• MDS UPDATES: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Downloads/MDS-30-SECTIONS-A-AND-GG-DOCUMENT.pdf

References

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• https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-07-30-2.html

• https://www.ahcancal.org/facility_operations/MedicareRAC/Pages/RACContractors.aspx

• https://www.pepperresources.org/

• https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Downloads/MDS-30-QM-User%E2%80%99s-Manual-V90.pdf

• https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_p_ltcf.pdf

• https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-15-25.pdf

References

the big wide world of mds data · measure quality metrics 2. public reporting of quality measures...

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