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

NCHIMA 66 th 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

Background CMS Payment Model Evolution • Move away from payment for volume • Improve care coordination Lower • Promote alignment of financial and Cost other incentives to increase the quality of care and lead to better outcomes Goals ‐ increase % of Medicare provider payments linked to quality outcomes and alternate payment models • Quality: 2016 85%  2018 90% Improve • APMs: 2016 30%  2018 50% Quality HHS Secretary Burwell Posting January 2015 4

Background CMS Payment Model Evolution (cont) 5

The Impact of CDI on Value Based Outcomes • Payment • Public profiles • Performance • Patient Care ICD Code 6

Background Category 2 – Fee for Service Link to Value • Hospital Pay for Performance Programs 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% 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) 7

Pneumonia Mortality Inpatient/Ambulatory CDI Impact Risk Standardized Mortality Rate • Cohort Pneumonia (v9.2) – Effective FY 2017 (IPPS FY2015) – Inclusions • Inclusion Pneumonia as principal diagnosis, or – Exclusions • Sepsis as principal diagnosis with • Risk Adjustment 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 8

Pneumonia Mortality Inpatient/Ambulatory CDI Impact (cont) ID Key takeaway ‐ All discharges in the cohort “count” in the measure; not limited to mortalities 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” 9

Pneumonia Mortality Inpatient/Ambulatory CDI Impact (cont) Risk Standardized Pneumonia Mortality Comorbid Categories with 90% Risk Adjustment Impact PsychDIS 2.31% VERTEBRAL_FRACTURES 3.05% HxMI 3.42% PARALYSIS_FUNCTDIS… 3.44% FIBROSISLUNG… 3.62% IRON_DEFICIENCY… 4.05% HEMATOLOGICAL… 4.55% CHF… 4.83% CARDIO_RESPIRATORY… 5.20% LIVERDIS 6.81% DEMENTIA 8.26% MALNUTRITION… 17.09% MCANCER… 24.42% 0.00% 5.00% 10.00% 15.00% 20.00% 25.00% 30.00% 10

Pneumonia Mortality Suboptimal Comorbidity Capture • Clinical documentation and/or code reporting opportunities? 11

Pneumonia Mortality Risk Adjustment – CMS vs. APR‐DRG • Different risk adjustment methodologies – different results Outcome CMS P4P Program Population CMS APR‐DRG Measure IQRP Mortality CABG N/A IQRP Mortality COPD HVBP FY2021 HVBP Mortality HF HVBP Mortality MI HVBP Mortality Pneumonia IQRP Mortality Stroke N/A 12

Background Category 2 – Fee for Service Link to Value • Physician fee schedule adjustments Merit‐Based Incentive Payment System (MIPS) Physician Quality Reporting System PQRS Value Based Modifier Program VBM Meaningful Use Electronic Health Record CEHRT Incentive Program Certified HER Technology • Providers are rated on four criteria weighted and scored to create a composite score; the score adjusts provider fee for service reimbursement Calendar Year 2019 2020 2021 2022 Physician Fee +/‐ 4% +/‐ 5% +/‐ 7% +/‐ 9% Schedule Adj Incentive 27% Data in 2017 impacts performance in 2019 13

Value Based Modifier (VBM) Inpatient/Ambulatory CDI Impact • Acute composite index – Hospital admissions with select acute diagnoses • Bacterial pneumonia • UTI • Dehydration Bacterial Pneumonia Principal Diagnosis Codes 14

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 Diabetes Principal Diagnosis Codes ‐ Excerpts 15

Value Based Modifier (VBM) Inpatient/Ambulatory CDI Impact • • Medicare spending per Part A and Part B costs beneficiary measure • Immediately prior to, during, and (MSPB) for 30 days following a qualifying stay • Risk adjustment methodology ‐ Hierarchical Condition Categories (HCC) The HCC risk adjustment methodology is also utilized by payers (Medicare Advantage, some commercial) to determine physician payment rates. 16

HCC Impact on Payment Medicare Advantage • 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. Risk Adjustment Factor Diagnosis codes are Risk scores are (RAF) impacts submitted on claims calculated reimbursement for next calendar year

HCC Impact on Payment Medicare Advantage ‐ Example No Some ALL HCC Diagnoses HCC Diagnoses 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 $4,858 $8,870 $50,645 Payment Base Rate: $800/month Note: Values are for illustrative purposes only

HCC Impact on Payment Medicare Advantage – Example (cont) HCC 17 HCC 17 Diabetes with Acute Diabetes with Acute • Diabetes, Type I with ketoacidosis Complications Complications 0.378 0.378 HCC 18 HCC 18 Diabetes with Chronic Diabetes with Chronic • Diabetes, Type I with renal Complications Complications manifestations, u/c 0.378 0.378 HCC 19 Diabetes w/o • Diabetes, complication unspecified 0.121 Note: Values are for illustrative purposes only

Physician Performance Quality Resource Utilization Report • Clinical documentation and/or code reporting opportunities? 20

Background Category 3 – APM Build on Fee‐for‐Service Infrastructure • The Comprehensive Care Joint Replacement Payment Model (CJR) • Hospital Mandatory bundled payment for defined repayment episode of care • 90 day episode • Total joint replacements lower extremity Above (MS‐DRGs 469, 470)(Includes fractures) target • price Two sided payment model • Hospital accountable for financial risk Performance Year • April 1, 2016 through December 31, 2020 episode cost reconciliation Below target Hospital Quality price reconciliation Composite payment Score 21

CJR Costs Included in the Episode • All related services/ items paid under Medicare Part A or Part B 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 22

CJR Costs Excluded in the Episode • All related services/ items paid under Medicare Part A or Part B Excluded Services* Inpatient readmissions excluded using MS‐DRGs. Categories: • Certain inpatient admissions • Oncology • Certain Part B services • Trauma medical • Services and clotting factors for • Chronic disease surgical, e.g., hemophilia prostectomy • Inpatient new technology payments • Acute disease surgical, e.g.., • Outpatient transitional pass‐through appendectomy payments for devices Part B services excluded using principal ICD‐10 code. Categories: Source: CMS CJR Final Rule • Acute disease – e.g., severe head injury • Chronic disease – selected on diagnosis basis based on likelihood of impact by LEJR 23