3 rd Annual Association of Clinical Documentation Improvement Specialists Conference

1. 3rd AnnualAssociation of Clinical Documentation Improvement Specialists Conference

2. Inpatient Medicare Advantage: HCC Capture Through CDI Gloryanne Bryant, BS, RHIA, RHIT, CCS, CCDS Regional Managing Director of HIM NCAL Revenue CycleKaiser Foundation and Hospitals

3. Goals/objectives • Provide an Overview of Hierarchical Condition Categories (HCC) and payment methodology • Learn the Similarities and Differences between MS-DRGs and HCCs • Understand the Documentation and Coding issues • Learn how to Incorporate MA into your CDI program and processes

4. A little Medicare quiz #1 There are four types of Medicare coverage • True or False? #2 Medicare Advantage is also referred to as Medicare Risk, Medicare C, Medicare Managed Care • True or False?

5. A little Medicare quiz #3 How many citizens were enrolled in Medicare in 2009? • 35 million, or 45 million, or 50 million, or 55 million #4 Medicare headquarters are in Washington, DC. True or False? #5 Of all Federal Government expenditures, Medicare is in the top 3. True or False?

6. Medicare beneficiaries & chronic conditions

7. Medicare • There are several types of Medicare Healthcare coverage: Medicare A, Medicare B, Medicare C, and Medicare D (or Rx plan). • Medicare Advantage is often referred to as MA, Medicare C, Medicare Risk, Medicare Capitation, and Managed Care. • 2009 it was reported that there were 45 million people on Medicare, with 22% of these being enrolled in private Medicare Advantage plan.

8. Medicare Advantage plan enrollment 2009

9. Medicare Advantage enrollment

10. Medicare Advantage (MA) model • To ensure a health-based risk assessment system, CMS monthly capitated payments need to take into consideration the severity of illness of the patient. • Diagnosis information is collected for each patient which will determine the payment for the following year. • The intended goal is to pay Health plans appropriately for the relative risk of their patients. • Promote fair payments and reward organizations for efficiency and excellent care for the chronically ill.

11. What is Risk Adjustment? • Medicare Advantage adjusts their monthly per capita payments to Health Plans to take into account the relative health of their members; “Risk Adjustment.” • Health Plans receive less payment for healthier members/patients and more for sicker members. • The relative health or “risk adjustment factor” is based on diagnoses (coded data) submitted by the Health Plan in the prior year. • The “risk” score comes from the weight (assigned value) of the Hierarchical Condition Categories (HCC) 7

12. Reimbursement model from CMS Under CMS guidelines, providers are reimbursed based on that patient’s: • Membership/Patient • Age • Sex • Geographic Area • Risk for future healthcare costs • Each calendar year, based on diagnosis identified, documented, and coded (meeting the definition of a reportable condition)

13. How does the model work? • CMS adjusts Medicare Advantage payments to private healthcare plans based on health expenditure risk of enrollees. • The “CMS-HCC model uses demographics and a diagnosis-based medical profile captured during all clinician encounters—both inpatient and outpatient—to produce a health-based measure of future medical need.” • Medical Care, Vol 43, Number 1, January 2005, pg. 34. • This methodology is used to calculate payments for Medicare managed care plans (Medicare Advantage or Medicare Part C).

14. Why is this important to know? • The diagnoses captured predict the future care expenditures. • If we document, address, and capture/code these diagnoses: • Our patients receive better quality care • Clinical data represents the severity of our patients • Providers receive the appropriate reimbursement for the care we provide

15. Sources of diagnostic information • Diagnosis information is collected from the following sources (continuum of care for the calendar year): • Hospital inpatient principal & secondary diagnoses (internal & external) • Hospital outpatient diagnoses (internal & external) • Physician diagnoses (internal & external) regardless of setting (e.g., could be from hospital rounding, SNF rounding, ICFs, Dialysis Centers, and home visits) • Diagnoses made by clinically trained non-physician providers (e.g., psychologists, podiatrists, nurse practitioners, physician assistants) • Although most Medicare Advantage diagnoses for HCCs are made in the ambulatory setting, there are some “specific” HCCs in the inpatient setting with opportunity. 15

16. ICD-9-CM and HCCs

17. HCC Category Description 1 HIV/AIDS 2 Septicemia/Shock 5 Opportunistic Infections 7 Metastatic Cancer and Acute Leukemia 8 Lung Upper Digestive Tract and Other Severe Cancers 9 Lymphatic Head and Neck Brain and Other Major Cancers 10 Breast Prostate Colorectal and Other Cancers and Tumors 15 Diabetes with Renal or Peripheral Circulatory Manifestation 16 Diabetes with Neurologic or Other Specified Manifestation 17 Diabetes with Acute Complications 18 Diabetes with Ophthalmologic or Unspecified Manifestation 19 Diabetes without Complication 21 Protein-Calorie Malnutrition 25 End-Stage Liver Disease 26 Cirrhosis of Liver 27 Chronic Hepatitis 31 Intestinal Obstruction/Perforation 32 Pancreatic Disease 33 Inflammatory Bowel Disease 37 Bone/Joint/Muscle Infections/Necrosis 38 Rheumatoid Arthritis and Inflammatory Connective Tissue Disease 44 Severe Hematological Disorders 45 Disorders of Immunity51Drug/Alcohol Psychosis 52 Drug/Alcohol Dependence54Schizophrenia 55 Major Depressive Bipolar and Paranoid Disorders HCC list See Appendix for Complete List of HCCs

18. Hierarchical Condition Categories — related diseases • Hierarchies are established so that each patient is onlypaid for the most severe manifestation among relateddiseases. • For instance, ischemic heart disease diagnoses are organized in the Coronary Artery Disease (CAD) in the hierarchal category. • The CAD hierarchy consists of three Hierarchical Condition Categories (HCC) arranged in descending order by clinical severity and cost. • HCC 81 for Acute Myocardial Infarction (AMI) through HCC 83 for Coronary Atherosclerosis/Other Chronic Ischemic Heart Disease. • A patient with a diagnosis code in HCC 81 is excluded from the payment grouping in HCCs 82 and 83, even if these ICD-9-CM codes are present, as the hierarchy is applied. 18

19. Disease hierarchies • 33 of the 70 HCCs are in hierarchies: • Hierarchy: group of HCCs with same disease at sequential levels of severity (and costs) • Example: Diabetes = HCC 15, 16, 17, 18, 19 depending on type of complications • Purposes: • Diagnoses are clinically related and ranked by cost • Takes into account the cost of the lower HCCs reducing the need for coding proliferation • Risk factors within a hierarchy are additive; the highest “trumps” the lower conditions

20. CMS Model Categories and Hierarchies (HCCs) — examples Diabetes 1) Diabetes w/Renal or Peripheral Circulatory Manifestation 2) Diabetes w/Neurologic or Other Specified Manifestation 3) Diabetes w/Acute Complications 4) Diabetes w/Ophthalmologic or Unspecified Manifestations 5) Diabetes w/o Complications Cancer 1) Metastasis Cancer & Acute Leukemia 2) Lung, Upper Digestive Tract, & Other Severe Cancers 3) Lymphatic, Head & Neck, Brain, & Other Cancers & Tumors 4) Breast, Prostate, Colorectal & Other Cancers & Tumors Kidney Disease 1) Dialysis Status 2) Renal Failure 3) Nephritis Vascular Disease 1) Vascular Disease w/Complications 2) Vascular Disease 3) Chronic Ulcer of Skin, Except pressure (decubitus)

21. Hierarchical Condition Categories — unrelated diseases • For unrelated diseases, HCCs accumulate. • For instance, a patient with heart disease, stroke, and cancer will have three separate HCCs (payments) totaled together for the year. • The predicted cost will reflect increments for each of these three HCC categories. • This model also considers the fact that some diseases interact and that the predicted cost may be more than the sum of the separate increments. • For instance, the presence of both CHF and COPD leads to a higher cost than the predicted cost for the sum of these conditions. CMS calls this an “interaction term.” • To improve clinical validity and predictive accuracy, the interaction among common and high-cost chronic diseases was considered. • These include diabetes, cerebrovascular disease, vascular disease, COPD, CHF, and renal failure. 21

22. CMS reimbursement is based on the Hierarchical Condition Categories (HCC) • Providers are reimbursed based on the most severe diagnosis within each category. • Disease categories are accumulated — that is, reimbursements are based on the sum of all chronic conditions diagnosed in different hierarchical categories.

23. Medicare Advantage HCC annual payment methodology — example * Dollar amounts are rounded estimates and do not reflect actual reimbursement rates

24. Medicare Advantage HCC annual payment methodology — example (cont.) * Dollar amounts are rounded estimates and do not reflect actual reimbursement rates

25. HCCs that often are seen in the inpatient setting Note: a weight of 0.267 would = $2,507 approx reimbursement

26. Documentation is a focus • It’s a QUALITY issue: • All diagnoses considered in the medical decision-making process need to be documented. • Explicit documentation makes the diagnosis apparent to other providers and ensures that internal and external reporting accurately reflects the quality of care provided. • It’s a REIMBURSEMENT issue: • Appropriate CMS reimbursement is received only if the diagnoses are documented and coded appropriately. Requires greater efficiencies

27. ICD-9-CM codes selected • Under Medicare Advantage certain conditions and/or disease have been identified to be “higher risk,” higher cost and resources. • Annually CMS reviews the list of ICD-9-CM codes that are considered to be conditions that are classified under MA as “risk.” • There are similarities to MCC/CCs and overlap.

28. ICD-9-CM codes into HCCs • The selected ICD-9-CM codes are then “clustered” into categories or hierarchy condition codes (remind you of grouping of DRGs) • For example, HIV/AIDS is within HCC 2 for ICD-9-CM codes:

29. ICD-9-CM HCC list

30. Specific payment for HCCs • Adjustments are made for HCC payment • Only for diagnosis NOT procedures • This is an “ANNUAL” payment and covers both hospital, outpatient and physician. • Most conditions/diagnoses appear in the outpatient physician clinic setting. • HOWEVER, certain diagnoses are most likely to occur in the acute care hospital setting. • These include: Sepsis, Acute respiratory Failure, Malnutrition, Aspiration pneumonia

31. General rules for other (additional) diagnoses • For reporting purposes, the definition for “other diagnoses” is interpreted as additional conditions that affect patient care in terms of requiring: • clinical evaluation; ortherapeutic treatment;or diagnostic procedures;or extended length of hospital stay;or increased nursing care and/or monitoring.

32. The UHDDS item #11-b • Other diagnoses as “all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay. Diagnoses that relate to an earlier episode which have no bearing on the current hospital stay are to be excluded.”

33. Example from a recent audit • 75-yr-old patient admitted with Sepsis (this is documented, and was coded), in addition, the patient also has a history of hypertension as well as glaucoma, which is documented and coded. • On admit to ICU, the patient was put on a Bipap, and ABGs were abnormal x2 over 24 hrs. (No documentation of possible or confirmed respiratory compromisein the chart by the provider). Patient was treated with antibiotics and progress note lists “PNA,” but the patient continues downhill after 5 days. • What was the risk of mortality? • Was this patient sicker than the data shows? • Did we get the accurate reimbursement? • Were all HCCs documented? • Action: Query or discuss with the physician • Result: Respiratory Failure = 518.81 (ICD-9-CM) = HCC 79

34. Example from a recent audit • 86-year-old with CHF admitted with SOB, edema, and weakness. Hx of diabetes type II. Put on O2, and Respiratory therapist noted the patient was hypoxic but no documentation by the provider of this. (Cannot code from the Respiratory Therapy note.) Per nursing assessment, patient has diabetic peripheral neuropathy, and blood sugar was 350 on sliding scale. Blood sugar drawn over 3 days, not documented by the provider (cannot code from nursing notes but they do provide clues). • What was the risk of mortality? • Was this patient sicker than the data shows? • Did we get the accurate reimbursement? • Were all conditions addressed? • Action: Query or Discuss with the physician • Result: • Hypoxemia = 799.02 (ICD-9-CM) = $5427 HCC 79 • Diabetic peripheral neuropathy = 250.70 (ICD-9-CM) = $4769 HCC 15

35. Risk score • Male, 80 years old: demographic score – 0.597HCC 18 – Diabetes with Ophtho – 0.259HCC 80 – Congestive Heart Failure – 0.410HCC 108 – COPD – 0.399 • Total Risk score = 1.665 • Divide by normalization factor of 1.03, risk score = 1.616

36. Data submission is vital • Data submission occurs rather than individual UB-04 claims • Data is submitted twice a year usually • Retrospective resubmission of data is allowed • Retrospective documentation and coding audits should be routine • The time limit IS NOT the same as MS-DRGs • 2008 data resubmission can occur up to the end of 2009 and so on

37. Risk Adjustment vs. Fee for Service (FFS) • Key differences between Risk Adjustment and Fee for Service: • Ambulatory FFS payments are driven by visit/volume and number and level of procedures (including CPT E/M) whereas ambulatory risk adjustment payment is driven by ICD-9-CM diagnoses. • For risk adjustment, each diagnosis must be captured once per calendar year in a face-to-face visit with a CMS recognized provider (physician, NP, PA, etc.). Visit volume is not relevant. • Inpatient FFS payments are driven by DRGs assigned which are grouped for each discharge. Principal diagnosis and secondary diagnosis are key. Risk adjustment, DRGs are not relevant but the diagnosis and secondary Dx count on an annual basis. • For risk adjustment, payment does not vary based on site of service. Diagnosis sources are inpatient & outpatient hospital and physician settings. FFS payment methodology varies by site or setting.

38. National healthcare budget perspective

39. NCAL Kaiser CDI program Get the right information, in the right place, at the right time EHR

40. CDI mission and vision • To provide and sustain accurate, timely, and complete clinical documentation in support of • Patient safety and quality of care • Improved coding and data for internal and external users and reporting • Accurate and comprehensive reimbursement

41. CDI goals • Understand the importance of documenting the patient’s acuity of illness by capturing the severity of illness (SOI) and risk of mortality (ROM) – the patient’s overall disease burden • Accurately capture this information in the medical record • Become familiar with ICD-9-CM codes that impact reimbursement in the CMS-HCC model • Understand IPPS MS-DRG payment methodology and the impact of MCC/CCs • Ensure that updated diagnoses (e.g., obtained through diagnostic studies) are added to the medical record • Ensure that information documented in the inpatient medical record is translated into specific, codable diagnoses

42. Clinical Documentation Integrity Program • Initiatives • Provide HCC training for CDI Consultants • Perform concurrent chart reviews to ensure documentation reflects the severity of illness of patients • Work with the providers when documentation is incomplete or vague • Results • Documentation will more accurately reflect the severity of illness of the patient • Reimbursement will be more appropriate for the care that is rendered to each patient

43. What will the clinical documentation program NOT do? • It does not challenge the physician's medical decision-making • It does not make the physician into a coder • It does not make the CDI consultant into a physician or into a hospital coder • It does not require more time to document completely • It does not alter – but rather enhances – documentation

44. The CDI compliance connection • Clinical documentation improvement and the role of the Clinical Documentation Integrity Consultants (CDIC) staff are an important component of our regional compliance program. • Senior Consultant and Consultant – partnership of clinical and HIM professional • By communicating, promoting, and partnering with physicians for improved clinical documentation, the hospital may reduce the risk for submitting claims that are insufficient, incorrect, or lack medical necessity.

45. Documentation • Document – To document a chronic, co-existing condition is to list it in the encounter note as a condition that exists and is considered in the Medical Decision-Making process in determining treatment. • Address – To address the condition is to provide a written statement of the condition and its status. It is not necessary to treat the condition to address its status. • Capture – To capture the diagnoses is to add the diagnoses to the encounter or to choose a diagnosis from the KPHealthConnect (EMR) that best describes and represents the condition. It can also be added to the patient condition problem list.

46. Implementation approach • Phase I – Medicare Advantage Admissions • HCC Focus – 20 specific diagnostic categories • Phase II – All Medicare Admissions • Medicare Advantage • Medicare Cost and Fee-for-service • HCCs, MS-DRGs, APR-DRGs • Phase III – All Hospital Admissions • This will depend on staffing requirements

47. PHASE I – HCC focus • Medicare Advantage Reimbursement is based on the Hierarchical Condition Categories (HCC): • We are reimbursed based on the most severe diagnoses within each category (HCC) • Disease categories are additive — that is, reimbursements are based on the sum of all chronic conditions diagnosed in different categories • Concurrent query and QA process

48. PHASE II – Case Mix Index (DRG-based) • The average of all DRG relative weights (RW) for all discharged cases within a given time frame • For Medicare • Can be multiplied times the hospital blended rate to render an expected Medicare reimbursement revenue. (RW x blended rate = payment) • Reflects the severity of the patient population served; a tertiary hospital should have an increased CMI in comparison to a rural hospital • Is dependent upon the documentation within the medical record • Is generally used as a benchmark measure for senior leadership • This can indicate documentation or coding problems exist

49. PHASE III – all payers(Case Mix Index impacted) • Review of all payers – inpatient setting • Target those that impact quality and outcomes • All inpatient cases are grouped to MS-DRG • Review OSHPD (Office State Hospital Discharge) – California specific quality indicators

50. PHASE I, II, and III – principal and secondary diagnosis Principal Diagnosis • That condition established after study, determined to have caused the patient’s admission to the hospital (UHDDS). Secondary Diagnosis • Secondary diagnosis is any condition that is documented by the physician and one of the following: (1) Clinically evaluated, or (2) Diagnostically tested, or (3) Therapeutically treated, or (4) Causes an increased Length of Stay (LOS) or nursing care Documentation that is codable