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UHC Webinar Series: Mining the Metrics of Risk Models

UHC Webinar Series: Mining the Metrics of Risk Models. Obesity and Malnutrition Palliative Care and DNR Status. May 30, 2012. Presented by Suzanne Rogers, RHIA, CCS, CCDS. Agenda. Introduction to the UHC Webinar Series: “ Mining the Metrics of Risk Models ”

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UHC Webinar Series: Mining the Metrics of Risk Models

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  1. UHC Webinar Series:Mining the Metrics of Risk Models Obesity and Malnutrition Palliative Care and DNR Status May 30, 2012 • Presented by Suzanne Rogers, RHIA, CCS, CCDS

  2. DRAFT 04.04.12 Agenda • Introduction to the UHC Webinar Series: • “Mining the Metrics of Risk Models” • UHC Risk Adjustment: brief re-cap • Documenting & Coding Series Focus #1 • Obesity, BMI • Malnutrition, BMI • End of Life • Palliative care • Hospice • DNR

  3. UHC Mining the Metrics of Risk Models Webinar Series • The purpose of this series of webinars will be to highlight some of the diagnoses & procedures that impact the UHC risk adjustment models or have the potential to impact these models in the future • Goals & Objectives of the Series: • Quarterly webinars with documentation and coding educational focus that will: • Demonstrate of how documentation and coding practice directly influences the administrative data used in benchmarking, performance improvement, and reimbursement • Encourage accurate, compliant, and consistent documentation and coding practice throughout the UHC membership • Explain the application of Official Coding Rules & Guidelines in a environment of federal regulations and audits • Examine how current documentation and coding practice of the membership will impact future UHC risk adjustment models • Measure improved consistency of coded and reported metrics • Baseline data will be collected for each focus topic prior to the webinar and then monitored going forward

  4. UHC Risk Adjustment Brief Re-Cap

  5. UHC Clinical Database • UHC receives data from members throughout the year. Data is sent with a minimum of 45 day lag time to allow for the completion of coding and billing cycles • The data feed contains many data elements such as: • ICD-9 diagnosis and procedures codes • Patient demographics such as age, race, sex • Admission source, admission status, and discharge disposition • Encounter physicians and their clinical specialty • Line item charge details • Primary and secondary payers • The MSDRG is not sent; UHC recalculates the MSDRG as well as a APR DRG for every inpatient encounter • UHC performs data quality checks, flags bad data which does not go to the data base, and applies the various risk adjustment models • The UHC clinical database risk adjusted data can be used for benchmarking and evaluating clinical care, patient outcomes and costs

  6. DRAFT 04.04.12 UHC Risk Adjustment: Brief Re-Cap • UHC recalibrates the CDB risk models annually • CDB discharges from major academic medical centers are used to build the models • A coefficient is assigned for each of the variables found to be statistically significant predictors of the outcome • Only conditions that are Present on Admissions (POA) are considered in the models • When using the database you can choose to report with the current (2011) or previous (2010) risk model

  7. Risk Model Information on Website From UHC CDB/RM home page, select Documents & Presentations drop down list and choose Risk Methodology The following screen should appear as a pop-up window Choose the Risk Model Summary for 2011

  8. Risk Model Information on Website Cont. • Many other resources that pertain to the risk models can also be found here such as: • Diagnosis & ICD-9 codes that define the AHRQ Comorbidities • ICD 9 diagnosis and procedures codes used in the risk models • Variable definitions for MSDRG 2011 Models • Definitions and tips on using the CDB • Interactive Risk Model Calculator

  9. Risk Model Information on Website Cont. You can use the Interactive Risk Model Calculator to calculate the risk adjustment for a particular encounter, to determine the impact of deleting or adding diagnoses or other data elements

  10. Coding Accurately and Completely • A diagnosis may not be in current risk models but can only be tested for impact on clinical outcomes if it is coded • What is coded today can be important in developing FUTURE risk models • POA is an important aspect of developing and applying the risk models • Query if UNKNOWN • Blank POA = NO for risk adjustment • Demographic data elements are key components of the risk models • Patient age, admit source & admit status should be verified • Learn how to access, read, and apply the risk models • Match the model to the medical record. What got coded? What was missed? What was the impact? Were the POA’s accurate?

  11. Obesity, Malnutrition and BMI

  12. Obesity, Malnutrition and BMI • Both obesity and malnutrition are factors in AHRQ risk adjustments for some Quality Indicators and Patient Safety Indicators • Both obesity and malnutrition are factors in UHC’s LOS, cost and mortality risk models • The ICD-9 diagnosis codes must have a POA of W, Y,1, or E to be considered in the risk adjustment process • The BMI V-Codes are EXEMPT from POA reporting and should appropriately be assigned ‘E’ or ‘1’ for POA exempt (do not leave blank) • POA indicators that are BLANK are translated to a N- Not Present on Admission for risk adjustment

  13. DRAFT 04.04.12 Obesity and Body Mass Index • Obesity currently a risk factor in 199 UHC risk models (57%) • Defined by codes: • 278.00 Obesity unspecified • 278.01 Morbid obesity • 649.1X Obesity complicating pregnancy • 793.91 Image test inconclusive due to excess body fat • V85.30 Body Mass Index between 30-39, adult • V85.40 Body Mass Index between 40-49, adult • V85.54 Body Mass Index pediatric ≥ 95th percentile for age • Excludes MSDRG 640-641 Nutritional and Metabolic Disorders • Excludes MSDRG 619-621 Operating Room Procedures for Obesity

  14. DRAFT 04.04.12 Obesity

  15. DRAFT 04.04.12 Obesity: Some Facts • A person is considered obese when his or her weight is 20% or more above normal weight • A person is considered obese if his or her BMI is over 30 • "Morbid obesity" means that a person is either 50-100% over normal weight or has a BMI of 40 or higher • The CDC estimates that 30% of adults are obese and 17% of all direct medical costs in the US are related to obesity • Being overweight or obese severely interferes with health and normal function as well as increases risk of morbidity and mortality Reference: Adult Obesity Facts: Center for Disease Control and Prevention website

  16. DRAFT 04.04.12 Obesity Coding and CDI Opportunity • What to look for and query for definitive diagnosis • Body habitus and/or BMI is often documented by nursing as part of an admission assessment (Joint Commission requires a nutritional assessment be done at admission) • You may also find this in the H&P as part of the physical exam or review of systems • Is the patient on a low fat diet or limited calories • Look for a dietary or nutrition consult or note • Are special measures being taken for imaging, transport or accommodations • Is there mention of poor imaging results due to body fat • Does OR report mention any difficulty or prolonged OR time due to the patient’s size and/or amount of body fat?

  17. DRAFT 04.04.12 Obesity Coding Guidelines • A code for the BMI can be assigned from nursing/ dietician notes ONLY if the treating physician documents the associated clinical diagnosis of obesity, morbid obesity etc. • To be coded the diagnosis of obesity, it must be clinically significant to the patient’s current hospital stay (it almost always is, so look for any measures taken or conditions resulting from pts weight) • To be coded a secondary diagnosis must affect patient care in terms of requiring: • Clinical evaluation • Therapeutic treatment • Diagnostic procedures • Extend LOS • Increased nursing care or monitoring Reference: AHA Coding Clinic

  18. Obesity Coding Guidelines Cont. • Obesity Dx must be POA; logically it would have to be since the pt is not likely to become obese during the hospital stay, HOWEVER the physician must document it as such (Dx in the H&P, document the duration, longstanding, etc) • Educate physicians on the importance of documenting the condition of obesity/morbid obesity and the clinical significance this condition has on the patient’s care and disease process

  19. Quarter 4, 2011: All Members 99% of Obesity Diagnosis are reported with a POA = Y

  20. Quarter 4, 2011: All Members 33-36% of adult BMI in obese pts are reported to UHC without a POA indicator 46% of pedi BMI in obese pts are reported to UHC without a POA indicator Assign POA indicator “1 or E” for Exempt so that the BMI codes can be used to calculate risk adjustment (POA’s that are BLANK = “NO” in risk models)

  21. How to Report on Your Obesity Dx POA Assignment Exclude MSDRG’s 619-621 & 640-641 (per AHRQ definition)

  22. Create an Advanced Restriction: AHRQ CC obesity codes and POA Flag- include all Save your advanced restriction as a custom list Click on underlined numbers to drill down to case profile

  23. Save your report by using the Save icon In Save Report: popup window give your report a name and file it under a existing or new group and click save

  24. Case #1 DRG 439 Disorder of Pancreas w/ CC • BMI present on admission indicator left blank & No Dx of morbid obesity coded. If added would increase Exp Mort to 0.53705 and Exp LOS to 3.53 • Combo of morbid obesity, OSA & hypoxemia consider QUERY for pickwickiansyndrome for second CC

  25. DRAFT 04.04.12 Malnutrition and BMI • Malnutrition currently a risk factor in 224 UHC risk models (64%) • Defined by Codes: • 260 Kwashiorkor • 261 Nutritional marasmus • 262 Other severe protein-calorie malnutrition • 263.0 Malnutrition of moderate degree • 263.1 Malnutrition of mild degree • 263.2 Arrested development following protein-calorie malnutrition (nutritional dwarfism) • 263.8 Other protein-calorie malnutrition • 263.9 Unspecified malnutrition • 783.21 Loss of weight • 783.22 Underweight • Excludes MSDRG 640-641 Nutritional and Metabolic Disorders

  26. DRAFT 04.04.12 Malnutrition

  27. Malnutrition: Some Facts • Currently there is no authoritative definition for the diagnosis or severity of malnutrition ….. • May 2012 Academy of Nutrition and Dietetics issued a consensus statement • Identification & Documentation of Adult Malnutrition (Undernutrition) • Continuum of characteristics or variables, no one marker for malnutrition • Inadequate intake, increased requirements, impaired absorption, altered transport, altered nutrient utilization can cascade into malnutrition • Inflammation is identified as an important underlying factor • Albumin /pre-albumin are indicators of the inflammatory response and not malnutrition • Two or more of the six characteristics recommended for diagnosis • Insufficient energy intake • Weight loss • Loss of muscle mass • Loss of subcutaneous fat • Localized or generalized fluid accumulation • Diminished functional status (hand grip) Reference: Journal of the Academy of Nutrition and Dietetics May 2012 Vol.112 number 5

  28. Figure. Etiology-Based Malnutrition Definitions. Adapted with permission from reference (8): Jensen GL, Bistrian B, Roubenoff R, Heimburger DC. Malnutrition syndromes: A conundrum vs. continuum. JPEN J ParenterEnteralNutr. 2009;33(6):710-716.

  29. Malnutrition: Some Facts Cont. • Diagnosis is usually based on several factors including some or all of the following: • Physical appearance: • Cachexia, atrophy, emaciation, unintended or unexpected weight loss • Risk factors: • Cancer, chemotherapy, ETOH, GI or pancreatic disorder, trauma, inflammatory responses, recent GI surgery • Test results: • Albumin as marker of inflammation, BUN, CBC, protein stores • None of these tests are markers for diagnosis rather they indicate underlying etiology for susceptibility • History: • Recent or rapid weight loss, decreased functionality, recent trauma or other stress on patient physiology

  30. DRAFT 04.04.12 Malnutrition: Coding and CDI Warning The terms “severe malnutrition”, “severe calorie deficiency”, “protein malnutrition”, “emaciation”, “protein deficiency”, “nutritional atrophy” • Code to either: • Kwashiorkor (260) • Nutritional marasmus (261) • Both these conditions are highly unlikely to occur in the general population and are usually associated with children in third world countries • Both these codes are current targets for review and denial by the OIG & RAC’s • Assign codes from category 263- Other and unspecified protein-calorie malnutrition • Educate the physicians on the terminology and code assignment

  31. DRAFT 04.04.12 Malnutrition: Coding and CDI Opportunity • Look for CLUES and query for clinical significance and/or definitive diagnosis (must meet the criteria for a reportable secondary diagnosis) • BMI <19 in nursing, dietary notes • Patient reported “loss of weight” (783.21) in H&P • Physical exam noted: underweight, cachexic, very thin or frail, failure to thrive • Conditions associated w/malnutrition such as, cancer and cancer treatment, HIV, s/p GI surgery, depression, prolonged illness and/or hospitalization, elderly, pancreatic disease, ETOH or drug abuse, swallowing difficulties Educate the physicians on the coding rules and code assignment Malnutrition can be coded even if it is the result of or an expected manifestation of the underlying disease such as cancer or pancreatic disorders

  32. DRAFT 04.04.12 Malnutrition: Coding and CDI Opportunity Cont. • Look for CLUES in treatments and orders and query for definitive diagnosis • TPN or other enteral feeding • Ensure, Boost, Carnation Instant Breakfast and other high protein/ high calorie supplements • Swallowing studies, GI consult, nutrition consult, OT/PT – ADLs Look for clinical evidence of malnutrition and/or treatment at admission A patient rarely becomes malnourished during a routine hospital stay Educate and query for malnutrition documentation in the H&P, admit note or designated as being present on admission

  33. Quarter 4, 2011 All Members In 17% of the cases the POA indicator did not allow the DX to be considered for risk adjustment: POA= No, Blank, Unknown

  34. Report on Your Malnutrition Coding Performance Create an Advanced Restriction: Exclude MSDRG 640 Create an Advanced Restriction: AHRQ CC malnutrition codes & POA flag- include all (be sure to save your Advanced Restriction as a custom list for future reporting)

  35. Report on Your Malnutrition Coding Performance Cont. Click on underlined case numbers to drill down to case profiles In this example 21% of malnutrition codes are indentified as: POA =No, Not Present on Admission

  36. Clarify this diagnosis is 262 Other severe protein-calorie malnutrition more appropriate Look for clues of present on admission Pt started on enteral nutrition on admission LOS is only 4 days Pt has oral cancer Pt has a trach and gastrostomy Query for diagnosis based on treatment and pts comorbidties

  37. Change “sort by” to Discharge Phys Specialty Change Advanced Restriction to POA =N Focus on General Medicine: Perform some chart reviews to substantiate Provide education for CDI, coders and Gen Med physicians based on finding and examples

  38. Palliative Care and DNR

  39. DRAFT 04.04.12 Palliative Care and DNR (Do Not Resuscitate) • Palliative care (V66.7) is in 27 UHC risk models • Exempt from POA reporting • Always coded as a secondary diagnosis • New code for Do Not Resuscitate (V49.86) • POA required • Not in risk models yet, but data is being collected for future consideration • As of July 2012, palliative care will no longer exclude a case from Core Measures • Comfort care or DNR must be documented for exclusion

  40. DRAFT 04.04.12 Palliative Care (V66.7): Some Facts • The National Institutes of Healthdefines palliative care as relief of symptoms without curing disease. Hospice care, care at the end of life, always includes palliative care. But you may receive palliative care at any stage of a disease. The goal is to make you comfortable and improve your quality of life. • CMS does not consider palliative care, hospice care, or comfort care synonymous even though the code assigned for all will be V66.7 • The level and type of care being given must be clearly documented in the record for Core Measures reporting and hospice reimbursement

  41. Palliative Care (V66.7): Some Facts Cont. Some indications of palliative care could be: • Withdrawal of any treatment or therapy (e.g. extubation, d/c-ing antibiotics, vasopressors, other therapeutic drugs • Addition or increase of opiates and other pain relief treatments • Treating symptoms, but not the cause/disease (e.g. drainage, relief of pressure, enteral feeding, oxygen by nasal cannula etc) • Transfer out of critical care setting, possibly to specialized palliative care unit/bed or even hospice Remember palliative care can be given in non-terminal cases, it is not always end of life

  42. DRAFT 04.04.12 DNR (V46.89): Some Facts • DNR (do not resuscitate) is a physician order not to perform CPR or ACLS • Can also be called a “no –code” or DNR/DNI • Palliative care and DNR/DNI are not the same • Patient can be a DNR and NOT be on palliative care & vice versa • You can not assume one because the other is documented • Patient can be DNR on admission or can request DNR status anytime during an admission. • Living will, advanced directives

  43. DRAFT 04.04.12 Palliative Care & DNR- Coding & CDI Opportunities • If a patient is on palliative care look for evidence of a DNR, and query for physician documentation so both can be coded • DNR/DNI may be documented in nursing notes, social worker or other care provider note • For DNR to be coded it must be documented by a treating physician • If a patient/family decide on withdrawing treatment and/or transfer to hospice, be sure to have that documented and code the V66.7 if comfort measures are started prior to transfer

  44. DRAFT 04.04.12 Palliative Care & DNR- Coding & CDI Opportunities Cont. • Provide general education to physicians on how to document palliative care, comfort care and DNR as well as the dying process as appropriate • Remember the patient does not need to be terminal to be receiving palliative care or have a DNR order • When a patient is DNR or on palliative care and they die; look for the associated conditions of the dying process and query physician to document • Do not miss out on documentation and coding of CC’s, MCC’s diagnoses of the dying process

  45. DRAFT 04.04.12 The Dying Process: What Might not be Documented/Coded

  46. Resource • Addendum: • Table of risk models with obesity, malnutrition and palliative care is included as a hand out for use in identifying impact of these codes on the various risk models

  47. Questions? Thank You rogers@uhc.edu

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