Teaching physicians: What’s in it for me (WIIFM)
Margi Brown, RHIA, CCS, CCS-P, CPC
Objectives
This “what’s in it for me” session will cover how to get the busiest physician/provider’s attention and keep it with the goal of accurate documentation in mind.
Topics of discussion
Establishing the initial contact.
Determining the focus of the presentation(s) and other efforts.
Compiling numbers that impact the physician.
Providing take-away tools.
Sparking interest in their office setting.
Avoiding potholes on the way .
Ensuring ongoing marketing and feedback .
Taking the next steps: Once they are hooked, then what?
Determine your bottom line
Hospitals and each physician need the most accurate and specific documentation that translates into correct and compliant coding to reflect the true complexity of care and severity of illness of their patients.
Initial steps
Before initiating any contact with providers …
Common goals
Set responsibility
Common goals
Set game plan: – Involvement, staging, calendar
Information likely disseminated through insurance company’s website
HealthGrades for hospitals
And soon MDs as well,provided that Consumer Checkbook wins its appeals
Physician public profiling
Pay for performance
Definition: Pay for performance (P4P) is a catchphrase for a management tool that establishes incentives for clinicians and institutions (e.g., hospitals) to deliver care that third parties deem is necessary and appropriate to achieve the highest-quality standards and best outcomes.
Current Metrics:– Process-oriented activities
Core Measures, Physician Quality Reporting Initiative (PQRI)– Infrastructure improvements
Principally information technology—CPOE – Patient outcomes
Risk-adjusted mortality
P4P goal: Increase value
Defined as outcomes (quality) ÷ Cost– Cost is easy to identify– Outcomes (quality) is not.
The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.
Discernment – What do we measure?– Process functions? (e.g., door-to-wire time)– Death? –Was it expected or unexpected?– Complication rates? –What is preventable and what is not?– Functional outcome? – Patient satisfaction?
Dissemination– How to we communicate our results to our constituency?
Goals for both
Physicians:– Encourage physicians to deliver their ethical obligation to practice evidence-
based medicine while better allocating resources– More proximal to the medical decision-making
Power of the pen Power of the knife
– Leverage with hospitals is professional relationships or to move their practice to a competitor
Hospitals:– Better develop systems and support
Less proximal but still critical– Leverage with physicians is professional relationships or medical staff
credentialing. Relationships – “Win-Win” between physician and facility Credentialing–like firing a poor-performing employee
Physician reimbursement“Tier and Steer” networks
Three proposed office visit tiers based on cost and “quality of care” by physician:
– $15/10% co-payment for tier 1 MD
– $30/20% co-payment for tier 2 MD
– $45/30% co-payment for tier 3 MD
Physician profiling example—Blue Cross of Texas
No changes—still measurable …
Where do you fall in the “bell” curve ?
or
OBS vs. inpatient—matching? Observation
Initial OBS day (3/3): 99218 –99220
Same DOS for admit/disch (3/3): 99234-99236
Disch: 99217
“Extra” days (2/3): 99211-99215 (per CMS)
Inpatient Admit, H&P (3/3): 99221-99223
Same DOS for admit/disch (3/3): 99234-99236
Subsequent day (2/3): 99231-99233
Disch: 99238 - < 30 minutes & 99239 - > 30 minutes
Complexity of medical decision-making Refers to the complexity of establishing a
diagnosis and/or selecting a management option as measured by the following:
– Number of possible diagnoses and/or management options
– Amount and/or complexity of data– Risk to the patient
1. Number of Diagnoses or Treatment Options
A DCB
Problem(s) Status Number Points Results
Self limited/minor
Established problem to examiner … stable/improved
Established problem to examiner … WORSENING
New problem to examiner w/additional workup planned
New problem to examiner w/no additional workup planned
1
max=1
max=2
1
2
3
4
TOTAL:
Complexity of medical decision-makingDetermined by (1) Number of diagnoses or treatment options, (2) Amount and/or complexity of data reviewed, and (3) Risks of complications and/or morbidity or mortality
Risk of significant complications, morbidity and/or mortality For E/M: The risk to the patient is based upon
the highest level of risk associated with the:– Presenting problem(s) – Diagnostic procedure(s)– Possible management options
Explain the data source
For both hospitals and physicians: – Documentation is the bottom line for both, leading
to the translation process of narrative diagnoses and procedures to numbers –codes
– Comparison of ICD-9-CM and CPT/HCPCS systems
– “Severity adjustment” – Mortality and morbidity rates
Hospital—IPPS—Inpatient Prospective Payment System methodology
One set payment to the hospital is determined by assignment:
Of codes for all (documented) diagnoses and procedures
To one Major Diagnostic Category (MDC)
Then further to one MS-DRG
All statistics are based on billed case-mix index (CMI)
Daily notes
Who?
What?
Where?
When?
How?
Why?
Why is the patienthere today?
Each note must:
Support what is coded and billed
Stand alone
Be legible
Show medical necessity
Medical necessity and the correct level "Medical necessity of a service is the overarching criterion for
payment in addition to the individual requirements of a CPT code.
It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted.
The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported.“
(CMS Claims Processing Manual (Publication 100-04), Chapter 12, Section 30.6.1 - Selection of Level of Evaluation and Management Service).
Reimbursement factor—RW
RW (Relative Weight)—Weighted number assignment
Hospital: This number is assigned to each MS-DRG. The assigned weight is intended to reflect relative resource consumption associated with each DRG.
Physician: This number is assigned to each CPT/HCPCS code.
CMI and the provider
Low CMI = low “severity” low “quality”?
High CMI = high expected cost & LOS?– My patient’s are sicker.
Measurement of high cost with low CMI = loss for patient, insurance company, hospital, and physician? (contracts?)
Credentialing, pay for performance – how does the physician rate?
Complete picture of quality, core measures, resource consumption, LOS, cost, compliance, audit risk, and much more.
Analyze the stats
Dr. 1 1.03 Dr. 2 0.96 Dr. 3 1.11 Dr. 4 1.07 Dr. 5 1.03 Dr. 6 1.05 Dr. 7 1.10 Dr. 8 1.17 Dr. 9 1.05 Dr. 10 1.04 Dr. 11 1.03 Dr. 12 0.95 Range = 0.95 – 1.17
If Medicare Reimbursement for case mix of 1.0 = $4500 per patient– Low = 4275– High = 5265
– most likely to risk RAC?– best mortality adjusted data?– discharge patients with more
symptom diagnosis? (chest pain, syncope, AMS…)
Analyze the stats
Doctor 1 1.28
Doctor 2 0.81
Doctor 3 1.15
Doctor 4 1.42
Doctor 5 1.09
Pulmonary /Critical Care
Range: 0.81 – 1.42
If Medicare reimbursement for case mix of 1.0 = $4500 per patient
– Low = 3645– High = 6390
– Have illegible handwriting?– Show the most resistance to coding
queries?– Will have the highest mortality (risk
adjusted)?– Are most likely to have his/her data
published in the newspaper
PD—Principal diagnosis
Coding guideline for inpatient hospital cases
Principal diagnosis– "that condition established after study to be
chiefly responsible for occasioning the admission of the patient to the hospital for care.“
Acute
Could notbe treated as
outpatient
Meets admitcriteria
Acutely treated
AggressivelyManaged
Principal Diagnosis
The principal and the why’s
Secondary diagnoses and other Comorbidity:
– A pre-existing condition that affects the treatment received or the length of stay
Complication: – A condition that arises during the hospital stay that affects the
treatment received or the length of stay
MCC or CC
Data integrity
Medical necessity
Where do you draw the line?
Discharge status
When does it count?
Example of vagueness
Provide real-life samples
Now ask: What was their billing for the physician?
– Critical care? – Level: 9923_: 1,2, or 3?– Medical necessity– Link back to their bell curve, their stats, and
compare to the hospital stats
POA defined
POA—Present on Admission purpose– To differentiate between conditions present on
admission and conditions that developed during an inpatient admission.
– The focus is to assess the timing of when the condition presented. Pre-existing or hospital-acquired?
Read more @ Share your Hospital Infection Story
Don't let a hospital kill you - CNN.com
Story Highlights. CDC: 99,000 people die annually from hospital-acquired infections ... Watch more on preventing hospital infections " ...
www.cnn.com
ABC News: Deadly Hospital Infections Occurring More
... the hospital even identified the type of infection …. abcnews.go.com
Stop Hospital Infections
LEARN MORE. SHARE YOUR STORY. DISCUSS. BLOG. Our Dedicated Activists ... legislators the perspective of living with and surviving a hospital infection. ...
www.stophospitalinfections.org
HAC –Yes or no, and why?
Indicator DefinitionHow a HAC will be treated with this indicator
YYes; POA Will assign to higher
weighted DRG
NNo; Not POA Will NOT assign to higher
weighted DRG
UUnknown: insufficient documentation
Will NOT assign to higher weighted DRG
W
Clinically Undetermined: Unable to determine based on clinical picture.
Will assign to higher weighted DRG
Liability implications
Were prevention guidelines followed?
Public reporting of infections, hospital-acquired conditions (HACs).
MD-specific data on HACs.
Increase in lawsuits against hospitals/MDs.
Some HACs or infections are expected.
How can hospitals/MDs defend against HACs?
Provider defined for POA
“Medical record documentation from any provider (a physician or any qualified healthcare practitioner who is legally accountable for establishing the patient’s diagnosis) involved in the patient’s care and treatment may be used to support the determination of whether a condition was present on admission or not; and the importance of consistent, complete documentation in the medical record cannot be overemphasized”
MLN Matters number: MM5499 Related Change Request Number: 5499, 091107 update and Transmittal #289 071707 update
Joint effort
“Finally, you should keep in mind that achieving complete and accurate documentation, code assignment, and reporting of diagnoses and procedures requires a joint effort between the healthcare provider and the coder.”
MLN Matters number: MM5499 Related Change Request Number: 5499, 091107 update and Transmittal #289
071707 update
Top Ten 2007 RW 2008/2009 MS-DRG(s) 291 w MCC: 1.2585 / 1.4465 292 w CC: 1.0134 / 1.0069
127 Heart Failure
1.0490
293 w/o: 0.8765 / 0.7220 193 w MCC: 1.2505 / 1.4327 194 w CC: 1.0235 / 1.0056
89 Simple Pneumonia with CC
1.0376
195 w/o: 0.8398 / 0.7316 469 w MCC: 2.6664 / 3.2901
544 Major Join Replacement or Attachment
1.9878 470 w/o MCC: 1.9871 / 2.0077 190 w MCC: 1.1138 / 1.3030 191 w CC: 0.9404 / 0.9757
88 Chronic Obstructive Pulmonary Disease
0.8878
192 w/o: 0.8145 / 0.7254 871 w MCC: 1.7484 / 1.8222
576 Septicemia w/o Vent > 96 Hours
1.5996 872 w/o MCC: 1.3783 / 1.1209 391 w MCC: 0.9565 / 1.0856
182 Esophagitis, Gastroenteritis, etc with CC
0.7853 392 w/o MCC: 0.7121 / 0.6703
64 w MCC: 1.5470 / 1.8450 65 w CC: 1.1901 / 1.1760
14 Stroke
1.2118
66 w/o: 1.0303 / 0.8439 377 w MCC: 1.3367 / 1.6073 378 w CC: 1.0195 / 1.0043
174 Gastrointestinal Hemorrhage with CC
1.0296
379 w/o: 0.8476 / 0.7565 682 w MCC: 1.4664 / 1.6403 683 w CC: 1.1942 / 1.1304
316 Renal Failure
1.2602
684 w/o: 0.9835 / 0.7305 689 w MCC: 1.0587 / 1.2301
320 Urinary Tract Infection
0.8769 690 w/o MCC: 0.8000 / 0.7581
National top 10 list
What do you mean?
Low H/H Insufficiency/distress Infiltrate Hypotension
Symptom, sign, or AMS, weakness, chest pain, … Contradiction (attending vs.
consultant) or terms
Lab/radiology/path
finding Acuity
Anemia … due to- Failure Pneumonia or CHF Shock. ? Type, ? other
Due to, Link, Diagnosis/disease
Clear and concise
Clinical significance
Acute, chronic, acute on chronic
Provide examples of inference “Clinically” or “reasonably” vs. actual documentation Meaning? Interpretations differ? CMS to set the policy:
– Determinations are “inconsistent”– Error rate is “compromised”
“lack of understanding documentation requirements” Disservice by “under-documenting”
– Continuity of pt care, severity, LOS, resources– Patient – prevent from obtaining necessary services?
Increased and inaccurate out of pocket costs?
Call it what it is
Obesity– Morbid obesity
Delirium
Sepsis vs. urosepsis
(VAP)—“Ventilator associated pneumonia” specifically documented by the physician
Hypoxia
“Acute” exacerbation …
Heart failure weighted
Did the decubitus exist POA?
Where was patient admitted from?
Is there a skin exam in the ER or by the admitting physician?
Check the H&P.
Skin breakdown, redness, when was this initially noted and by whom?
Is the diagnosis of “ulcer”, the type, the stage, and POA clearly documented?
Physician query is required.
Superficial well-defined decubitus ulcer
Before skin breakdown into an ulcer – redness
Wound progression “It is possible for a wound to
"go from a stage I wound to a stage III or IV" without the intermittent stage[s] being observed.
All wound stages were present just not obvious, hence the need to treat all wounds as serious with the potential of rapidly worsening.”
www.expertlaw.com/library/malpractice/decubitus_ulcers.html
Stage 4 decubitus ulcer
Values Commonly Used to Grade the Severity of Protein-Energy Malnutrition
Measurement Normal Mild Malnutrition Moderate Malnutrition
Severe Malnutrition
Normal weight (%) 90–110 85–90 75–85 < 75
Body mass index 19–24* 18–18.9 16–17.9 < 16
Serum albumin (g/dL) 3.5–5.0 3.1–3.4 2.4–3.0 < 2.4
Serum transferrin (mg/dL)
220–400 201–219 150–200 < 150
Total lymphocyte count (per mm3)
2000–3500 1501–1999 800–1500 < 800
Delayed hypersensitivity index†
2 2 1 0
*In the elderly, BMI < 21 may increase mortality risk.
†Delayed hypersensitivity index quantitates the amount of induration elicited by skin testing using a common antigen, such as those derived from Candida sp or Trichophyton sp. Induration grade 0 = < 0.5 cm, 1 = 0.5–0.9 cm, 2 = ≥ 1.0 cm.
http://www.merck.com/mmpe/sec01/ch002/http://www.merck.com/mmpe/sec01/ch002/ch002b.htmlch002b.html
Symptoms—Diagnoses?
Different diagnosis potential, different codes, and different MS-DRGs, with different reimbursement:
– Seizure–100-101– Syncope–312
Near syncope– Orthostasis
Orthostatic hypotension–312 – Vertigo, dizziness – (dysequilibrium)–149 – Weakness–947-948– Altered mental status–947–948– Decreased level of consciousness– Alteration of consciousness—081 – Dementia—884
Underlying cause due to more specific diagnosis?
AMS
Chest Pain
Mass
Weakness
Hypoxia
Insufficiency
Distress
SOB
Clarify Underlying Cause
Encephalopathy choices—Many types, many codes, many MS-DRGs, and RW difference
Alcoholic 291.2 MS-DRG 894-896 (FY08: 0.3571–1.0419, FY9: 0.3878-1.327)
Chronic cerebral ischemic 437.1 – MS-DRG 069 (FY08: 0.7339, FY09: 0.7157)
Due to dialysis 294.8-MSDRG 884 (FY08: 0.8431, FY09: 0.8992)
Hepatic 572.2 – MS-DRG 441-443 (FY08: 1.3973 – 0.9079, FY09: 106639-0.6982)
Hypertensive 437.2 – MS-DRG 077-079 (FY08: 1.4611-0.9839, FY09: 106233-0.7398)
Hypoglycemic 251.2 or – Wernicke’s 265.1 MS-DRG 640-641 (FY08: 0.9793-0.7248, FY09: 1.1138-0.6820)
Metabolic 348.31 or Unspecified 348.30 – MS-DRG 070-072 (FY08: 1.6212-0.9586, FY09: 1.8246-0.7650)
Post-traumatic 310.2 – MS-DRG 101-102 (FY08: 0.8258-0.8710, FY09: 0.7617-0.9584)
Toxic and Toxic-metabolic 349.82 – MS-DRG 091-093 (FY08: 1.3242 – 0.7710, FY09: 1.5747-0.6777)
Stroke MS-DRGs and weights
Sepsis clinical definitions
1991 ACCP/SCCM consensus conference definitions Sepsis = Infection + SIRS* Severe Sepsis = Infection + SIRS + Organ Dysfunction Septic Shock = Infection + SIRS + Organ Dysfunction + Hypotension
*Note: SIRS= Systemic Inflammatory Response Syndrome
Diagnosis Definition
Bacteremia Nonspecific laboratory finding of bacteria in the blood with no signs of illness.
Septicemia
Systemic disease associated with the presence and persistence of pathogenic microorganisms in the blood. Clinical manifestations may be a positive blood culture and fever.
Sepsis
Infection-induced syndrome in the presence of two or more manifestations of SIRS without organ dysfunction. Septicemia that has advanced to involve two or more manifestations of SIRS.
Severe sepsis Two or more manifestations of SIRS with organ dysfunction.
Septic shockSevere sepsis in which the cardiovascular system begins to fail, blood pressure drops, and vital organs are deprived of adequate blood supply .
Chronic kidney disease codes, GFR, and weights Stage I Kidney damage
with normal or high GFR > 90 585.1
Stage II Kidney damage with mild decrease in GRF 60-89 585.2
Stage III Moderate decrease in GFR 30-59
585.3
Stages I-III non CCs
IV Severe decrease in GFR 15-29 585.4
V Kidney failure .15 (or dialysis) 585.5
End Stage Renal Disease 585.6
HTN chronic kidney disease code each stage
HTN/HEART kidney disease
Stages IV –V CCs, Stage VI MCC
Simple pneumonia MS-DRGs
MS-DRG 195 Simple Pneumonia without MCC/cc– RW .8398 - FY08, 0.7316-FY09– GMLOS = 3.5– Multiple 5000 x RW .8398 = $4199.00 - $3658
MS-DRG = DRG 194 Simple Pneumonia with cc– RW = 1.0235 - FY08, 1.0056-FY09– GMLOS = 4.4 – Multiple 5000 x RW 1.0235 = $5117.50 - $5028
MS-DRG = DRG 193 Simple Pneumonia with MCC– RW = 1.2505 - FY08, 1.4327-FY09– GMLOS = 5.4 – Multiple 5000 x RW 1.2505 = $6252.50 – $7163.50
Hospital Base Rate = $5000
Respiratory failure
518.81 Acute Respiratory Failure = MCC
518.84 Acute & Chronic Resp Failure = MCC
518.82 Other pulmonary insufficiency = CC
518.83 Chronic respiratory failure = CC
Both are defined as an inadequate gas exchange by the respiratory system where the lungs cannot take in sufficient O2 or expel sufficient carbon dioxide to meet the needs of the body.
Average national mortality rates
Simple PNA--(DRG 193-195)– 2.5%
Complex PNA--(DRG 177-179)– 20%
Sepsis (DRG 871-872)– 20%
UTI (DRG 689-690)– 1.5%
Physician
Hospital Leadership
Clinicians
Coders
CDCI
A Clinical Documentation Coding Integrity (CDCI) program is a concurrent, retrospective, and proactive multi-disciplinary approach, with physician involvement with the goal to improve the completeness and specificity of clinical documentation to allow appropriate capture of patient severity.
Audience Questions???