With special guests Tamara A. Hicks, RN, BSN, MHA, CCS, CCDS, ACM, director of clinical documentation excellence for Wake Forest Baptist Health in Winston-Salem, North Carolina, and Judy Schade, RN, MSN, CCM, CCDS, clinical documentation specialist for Mayo Clinic Hospital. Both are members of the ACDIS advisory board and were among six board members who co-authored the newly-published ACDIS white paper on CDI productivity.
Every quarter since January 2014, the American Hospital Association (AHA) has collected and published survey data from its member facilities regarding government audit activities in its RACTrac surveys, reports, and related webinars. Although new Recovery Auditor contracts were awarded in October, the agencies won’t begin their reviews until sometime during the early months of 2017. In a message to members, the AHA encouraged hospitals to continue to monitor and record any CMS-related auditor activities including appeals, settlements, and claims’ reviews and communicate such data when the survey resumes in April.
Editor’s note: For additional information regarding recent Recovery Auditor development read “News: Court orders Medicare appeal backlog cleared by 2020.”
Continuing on its pay for performance agenda, CMS released information about new bundled payments related to cardiac diseases and hip replacements as well as a new Accountable Care Organization (ACO) opportunity for small practices, according to a December 20 release.
CMS says it paid more than $6 billion for heart attack treatment and bypass surgeries in 2014 but that the cost of such treatments, as well as percentage of 30-day readmissions, varied across the country. The release points to clinical trials which show rehabilitation improves patient outcomes but that only 15% of heart attack patients receive such care. The three new payment models related to heart attacks, heart surgery to bypass blocked coronary arteries, and cardiac rehabilitation.
The models aim to incentivize coordination of cardiac rehabilitation following discharge from the hospital for a heart attack or bypass surgery. Such payments will cover the same five-year period as the cardiac care bundled payment models, the release states.
For orthopedic considerations, CMS released one new payment model related to patients who receive surgery after a hip fracture beyond hip replacement. Providers will be accountable for the quality and cost of care provided to Medicare fee-for-service beneficiaries during the inpatient stay and for 90 days after discharge. The new models will operate over a period of five years beginning July 1, 2017. The surgical hip fracture treatment model will apply to hospitals in 67 metro areas, which are the same metro areas currently included in the Comprehensive Care for Joint Replacement Model, the release states.
It's time to submit nominations for the ACDIS Achievement Awards, to be presented at the 10th annual ACDIS Conference, May 9 - 12, at the MGM Grand in Las Vegas.
Do you know someone who launched a successful CDI program? Do you have a rising star on your CDI team? Perhaps you work with a colleague who helped advance a program beyond CC/MCC capture to collaborate with the quality or utilization review teams. Do you know an outstanding physician advisor with an innovative approach to educating physicians on good documentation habits, or someone who has served tirelessly as an ACDIS local chapter leader, conference committee member, or provided insight to the ACDIS Forum?
We invite you to nominate a colleague who has made significant contributions to the CDI field, who makes a difference in the profession, or is an outspoken advocate of CDI. We are accepting nominations in the following categories. Click on the links to view each award's criteria.
All nominations will be reviewed and voted on by the ACDIS Conference Committee in conjunction with ACDIS administration. You may upload supporting material with your nomination. Only one document upload is permitted per nomination. Three question fields relate to attaching supporting material and if you want to upload files for multiple fields, please combine into one document or zip them together.
Winners will be honored during the annual ACDIS Conference. Please fill out the nomination form by Friday, February 3, 2017. Click here: http://app.keysurvey.com/f/1095184/5e51/
Call it a no-brainer but recent research shows a “strong association” related to “clinically validated” patient safety indicators (PSIs) and patient outcomes such as increased length of stay and high rates of hospital readmissions and mortality. It is a no-brainer because PSIs are a set of measures that screen for adverse events that patients experience as a result of exposure to the healthcare system, events and conditions which, theoretically could be prevented by changes in care or processes.
The key phrase here is “clinically validated” as the new study, published in the American Journal of Medical Quality, cites various other recent reports which question PSI methodology including “significant coding and documentation errors as well as inadequate criteria for PSI classification.”
To clinically validate its sample, the Ohio researchers took more 2,089 PSI cases flagged between 2012 and 2014 and re-examined the records to ensure the appropriateness of that PSI designation whittling the list down to 1,847. When researchers analyzed this group of records, they identified different clinical results from predecessors’ findings. For example, previous studies agree that the two PSIs most significantly associated with excess mortality before discharge are postoperative respiratory failure and postoperative sepsis, but the present study found the highest mortality among patients with postoperative respiratory failure or postoperative physiologic and metabolic derangement.
“The present study findings underscore the importance of clinical validation of PSIs. The authors believe that avoidance of false positives, which can be the result of coding errors, coding misinterpretation, and insufficient documentation, may benefit hospitals that are at risk for disincentive by CMS.”
At a confidential agency briefing in August 2010, CMS officials outlined steps to recover more than $128 million in alleged 2007 overpayments from five Medicare Advantage insurer plans.
The briefing, recently released due to a Freedom of Information Act lawsuit filed by the Center for Public Integrity, pegged Florida Humana's payment error at $33.5 million, PacifiCare (a United Healthcare Washington state subsidiary) at $20.2 million, a New Jersey Aetna planat $27.6 million, New Mexico Independence Blue Cross at nearly $34 million, and Philadelphia-region Lovelace at just under $13 million, according to a Kaiser Health News article published at HealthLeaders Media.
The original audits, reportedly could not confirm that one-third of the diseases the health plans had been paid to treat actually existed, mostly because patient records lacked “sufficient documentation of a diagnosis.” Yet, CMS recovered a mere fraction of its earlier overpayment estimates due to disagreements over the efficacy of the audits, Kaiser Health News reported. The Center for Public Integrity reported that 35 of 37 health plans CMS has audited overcharged Medicare, often by overstating the severity of medical conditions such as diabetes and depression.
Nearly every professional association provides some type of vocation-specific guidance regarding ethical behavior. Periodically such recommendations need to be revised or updated to meet the changing needs of the industry. Such revision now comes from the American Health Information Management Association (AHIMA), the 89-year-old organization for those working in the HIM and coding field, when its 25-member committee released its “Standards of Ethical Coding,” on Dec. 12, 2016, according to an ICD-10 Monitor article by founding ACDIS member Gloryanne Bryant.
“The prior version of the Standards dates back to 2008, and we all know a lot has occurred in healthcare and coding since then, not the least of which is ICD-10,” Bryant writes.
AHIMA’s Standards is separate from its Code of Ethics in that it provides specific actions healthcare coders and HIM professionals need to take in their day-to-day work and offers case examples of how such actions might be played out. While not inclusive, the examples “address a wide range of behaviors and situations that apply to all settings,” writes Bryant.
Similar to ACDIS’ own Code of Ethics, AHIMA’s Standards include 11 such principals among them to “query and/or consult as needed with the provider for clarification and additional documentation prior to final code assignment in accordance with acceptable healthcare industry practices;” and to “refuse to participate in, support, or change reported data and/or narrative titles, billing data, clinical documentation practices, or any coding-related activities intended to skew or misrepresent data and their meaning that do not comply with requirements.”
AHIMA encourages all healthcare professionals related to HIM, coding, and medical record review and analysis to follow its Standards, stating that it applies to “individuals, whether credentialed or not; including but not limited to coding staff, coding auditors, coding educators, clinical documentation improvement (CDI) professionals, and managers responsible for decision-making processes and operations as well as HIM/coding students.”
“The coding professional faces daily challenges that can influence one’s behavior and/or actions, so taking the Standards and applying them in an effort to foster ongoing ethical excellence will require strong dedication,” according to Bryant.
CMS recently released its Short-Term (ST) Program for Evaluating Payment Patterns Electronic Report (PEPPER) with statistics through the third quarter of the fiscal year 2016 for hospitals nationwide.
The PEPPER allows hospitals to compare Medicare billing practices against those of other hospitals in the same state, in the same Medicare administrative contractor (MAC) or fiscal intermediary (FI) jurisdiction, and against national statistics. These comparisons enable a hospital to determine if it is an outlier, significantly differing from other ST acute care hospitals. Once such outliers are identified, CDI programs can perform an audit of related charts to ensure physician documentation appropriately captures the necessary information and, if opportunities for improvement are identified, provide targeted educational outreach and queries regarding the concern.
PEPPER data released to each hospital is facility specific, focusing on inpatient discharges in areas potentially at risk for improper Medicare payments.
The data in each free report is presented in tabular form, as well as in graphs, that depict the hospital’s target area percentages over time. The data also includes reports on the hospital’s top medical and surgical DRGs for one-day stays. All of the data tables, graphs, and reports in the PEPPER are designed to assist the hospital in identifying potential overpayments as well as potential underpayments.
It is distributed by TMF® Health Quality Institute under contract with CMS. Visit PEPPERresources.org to access resources, including the user guide, recorded training sessions, information about QualityNet accounts, frequently asked questions, and examples of how other hospitals are using PEPPER.
Editor’s Note: To learn how to use PEPPER at your facility listen to the April 26, 2016 webinar “PEPPER: Reduce Risk and Improve Revenue Integrity.” ACDIS members can read more in the CDI Journal article “Put PEPPER to proper use.”
In its 2016–2017 Work Plan, (read the related CDI Strategies article on the topic) the Office of the Inspector General (OIG) responsible for Medicare billing and reimbursement integrity called out DRGs in two specific areas—kwashiorkor and mechanical ventilation—for additional scrutiny, Elizabeth S. Goar reports in a recent For The Record article.
To combat such targets, pay attention to outdate templates capturing mechanical ventilation and to electronic health record system logic related to malnutrition, Goar writes.
In fact, in a December 2016 report, the OIG nabbed yet another medical center—Northside Medical Center of ValleyCare Health System in Ohio—for receiving roughly a million in overpayments out of a possible $11,076,498 in Medicare payments for 699 inpatient hospital claims that included a diagnosis code for a severe type of malnutrition from January 1, 2013, through June 30, 2015, according to an agency report. Northside disagreed with the OIG’s findings.
CMS recently updated its Recovery Audit program webpages with names of each new contractor, respective regions of responsibility, with links for updates, program reports, provider resources, and historical programs, according to Valerie A. Rinkle, MPA, a lead regulatory specialist and instructor for HCPro's Revenue Integrity and Chargemaster Boot Camp®, who listed to CMS’ Open Door Forum Call on the matter, and wrote about the subject for the Revenue Cycle Insider.
RA focus areas have yet to be released, but as with the previous contracts, CMS will approve all RA targets and post information on its website as well as on the RA portals. Inpatient medical necessity reviews, “one of the most significant and contentious audit topics under the first RAC” aren’t included in the current contracts, Rinkle says. Instead, contractors will conduct automated and complex audits and are encouraged to focus on issues identified by Comprehensive Error Rate Testing (CERT) reviews, according to the contract scope of work.
CERT targets are far from government secrets. Medicare publishes a Quarter Compliance Newsletter, which explored documentation and coding compliance concerns related to facet joint injections, radiation therapy, transluminal balloon angioplasty for hemodialysis fistulas, endovenous ablation therapy of incompetent vein, transurethral resection of the prostate (TURP), among others.
Once audits begin, audit findings may be communicated to providers either via a letter or an online portal each of the RAs will be required to maintain.
With special guest Allen Frady, RN, BSN, CCDS, CCS, CDI Education Specialist for HCPro and the Association of Clinical Documentation Improvement Specialists (ACDIS).
To view the OIG audit report on malnutrition referenced on this show, please click here.
To view the opinion piece "Stop the insanity related to the 2017 coding Guidelines,"please click here.
The Surviving Sepsis Campaign released new care guidelines updating its 2012 recommendations to help clinicians caring for patients with sepsis and septic shock.
The guidelines—crafted through collaboration between the Society of Critical Care Medicine and the European Society of Intensive Care Medicine—aim to “tell a story about the approach to treating the sepsis patient through a management continuum beginning with diagnosis, initial resuscitation, antimicrobial therapy, source control, fluid/vasoactive therapy, and progressing through organ support and adjunctive therapy recommendations,” according to its users guide.
Surviving Sepsis Campaign recommendations come on the heels of the so-called “Sepsis-3” definitions of sepsis and septic shock released in February 2016 by the Journal of the American Medical Association (JAMA). (Click here to read a related ACDIS Advisory Board position paper on the matter.)
A JAMA report released this month (January 2017) shows sepsis-related conditions account for a large number of hospital readmissions and its authors urged CMS to add sepsis to its list of readmission reduction targets stating that such readmissions require lengthy, and costly, hospital stays, Florian Mayr, MD, of the University of Pittsburgh Medical Center, told the Society of Critical Care Medicine, MedPage Today reported.
CMS’ readmission reduction program currently tracks patients who return to the hospital within a 30-day period following inpatient treatment for acute myocardial infarction (AMI), heart failure, chronic obstructive pulmonary disease (COPD), and pneumonia “because hospitalizations for these conditions are frequent and account for a large proportion of readmissions,” according to the study.
Sepsis readmissions accounted for as many, if not more, readmission cases than the conditions CMS currently tracks, study authors report.
Appropriate documentation for sepsis and its various manifestations continues to cause confusion for clinicians, CDI specialists, and coders alike, according to Allen R. Frady, RN, BSN, CCS, CCDS, CDI education specialist for ACDIS, in Middleton, Massachusetts, and Cesar M. Limjoco, MD, vice president of clinical services at DCBA, Inc., in Atlanta, Georgia, during a TalkTen Tuesday podcast on January 24.
The criteria CDI professionals use to discern whether a particular medical record reflects a patient with septic shock falls into an “80/20 rule,” Frady said, meaning its only accurate about 80% of the time, which is “unacceptable.”
“There’s nothing black and white in septic shock (as well as in medicine, in general) because certain circumstances may change the way diseases manifest,” Limjoco wrote in a companion piece.
So it’s easy for auditors to deny sepsis claims based on differing clinical criteria in the industry, Frady says.
“If you have an atypical patient, you have to go above and beyond in [investigating] the documentation,” Frady said. Since auditors have a definition and criteria for sepsis and septic shock, many see it as “low hanging fruit” for denials. “It’s easy enough to slap a denial on that,” Frady said.
“We need to get ourselves away from the trees to see the mountain,” Limjoco told TalkTen Tuesday listeners, meaning that while the new Surviving Sepsis care recommendations and Sepsis-3 definitions can be helpful, CDI specialists need to see the bigger patient picture to truly determine the severity of that individual’s condition.
More than 359,000 providers will participate in CMS’ four alterative payment models, which are aimed at compensating providers for quality of care and thereby delivering better care, according to an article published by Revenue Cycle Advisor.
The four models across healthcare settings include the Medicare Shared Savings Program, Next Generation Accountable Care Organization (ACO) Model, Comprehensive End-Stage Renal Disease Care Model (CEC) and Comprehensive Primary Care Plus (CPC+) Model.
This year, 572 ACOs are participating in the Shared Savings Program, Next Generation ACO Model, and CEC Model whereas 131 ACOs are participating in a risk-bearing track for these three models, Revenue Cycle Advisor reported. The CPC+ Models will welcome the participation of 2,893 primary care practices. Overall, the models will serve more than 12.3 million Medicare and Medicaid beneficiaries this year.
In addition, the Shared Savings Program has 99 new participants this year while the CEC Model welcomed 24 new participants.
Healthcare providers need to dedicate resources to increasing case-mix index, improving discharge disposition code accuracy, reducing readmission denials, and improving quality measures to reduce penalties, according to a report by HealthLeaders Media sponsored by Enjoin.
“If you are not appropriately documenting the complete picture of a patient, then it may have financial repercussions,” says ACDIS Advisory Board member James Fee, MD, CCS, CCDS, vice president of Enjoin, says in the report, “Don’t Underestimate the Impact of Clinical Documentation on your Revenue Stream.”
The report sites three main hurdles to improving clinical documentation:
Physician liaisons can help, the report states. “Organizations need a physician liaison—someone who can communicate from a clinical perspective but who is also knowledgeable and passionate about coding,” the report says. The second solution is daily audit reports.
Ultimately, the “whole idea is to build an infrastructure that enables you to capture information accurately at the point of care. The key part of that is the team mentality,” Fee says.
By Richard D. Pinson, MD, FACP, CCS
The 2017 Surviving Sepsis Campaign (SSC) guidelines to be published in the March 2017 issue of Critical Care Medicine have adopted the 2016 Sepsis-3 definition of sepsis as “life-threatening organ dysfunction caused by a dysregulated host response to infection” discarding the Sepsis-2 definition of sepsis as Systemic Inflammatory Response Syndrome (SIRS) due to infection. It now makes no distinction between sepsis and severe sepsis. The SSC guidelines have been the recognized clinical authority for the diagnosis and management of sepsis, severe sepsis, and septic shock since 2012.
Sepsis-3 defines organ dysfunction as an increase in the total Sequential Organ Failure Assessment (SOFA) score by 2 points or more from baseline. SOFA classifies 6 organ systems on a scale from 0 to 4 points using objective measures:
1 | Respiratory | pO2/FIO2 ratio |
2 | Coagulation | Platelet count |
3 | Liver | Bilirubin |
4 | Cardiovascular | Mean arterial pressure or vasopressors |
5 | Central Nervous System | Glasgow Coma Scale |
6 | Renal | Creatinine or urine output |
Unfortunately, the CMS Hospital Inpatient Quality Reporting (IQR) severe sepsis management measure (called SEP-1), which is abstracted by hospital quality departments, defines severe sepsis as SIRS due to infection with acute organ dysfunction. SIRS is defined as two or more of four criteria:
The SEP-1 measure definition of organ dysfunction definition is much different than SOFA.
If providers do not follow the SEP-1 treatment requirements when the SEP-1 organ dysfunction criteria are met, a deficiency in the quality of care for severe sepsis management will be reported. Following only the Sepsis-3 definition may allow many cases to “fall through the cracks” for SEP-1 reporting.
It remains to be seen how CMS will now react to the new SSC guidelines including the adoption of the Sepsis-3 definition which conflicts with the IQR SEP-1 standards. In the meantime, hospitals should make sure medical staff leadership is engaged with this complex challenge of reconciling authoritative clinical guidelines with the CMS quality reporting imperative.
So, what should CDI and coding professionals be doing about these changes? Here are some suggestions:
Editor’s Note: Pinson is the principal of Pinson & Tang LLC, and co-author of the CDI Pocket Guide. His views do not necessarily reflect those of ACDIS. Be sure to consult with your facility management and compliance departments. Contact Pinson at info@pinsonandtang.com.
Even after Medicare officials agreed that seniors cannot be denied coverage for physical therapy and other care based on their condition not improving, NPR News reported this week that patients are continuing to be turned away.
Several federal officials and Medicare advocates restarted their court battles to address the problem. “Many seniors have only been able to get coverage once their condition worsened. But once it improved, treatment would stop — until the people got worse and were eligible again for coverage,” the NPR article says.
Sometimes, providers assign a code which requires patient improvement and thus gets denied. Code assignment in these cases can not only ensure the proper reimbursement and coverage for the patient through CMS but ensure appropriate care gets provided at all.
"We still regularly get calls from people who are told they are being denied coverage," said Peter Schmidt at the National Parkinson Foundation in Miami, Florida says in the NPR report. In order to correct this problem, outside of the legal actions, further provider education will play a big role. Educating providers on how to code for treatment not predicated on the improvement standard could lead to greater coverage and better care for seniors.
Intensive care units are expensive, invasive, and supposed to be reserved for the sickest hospital patients, but more than half the time, they're not needed, according to research from LA BioMed and UCLA, HealthLeaders Media reported.
Researchers examined all of the 808 ICU admissions from July 1, 2015 to June 15, 2016 at Harbor-UCLA Medical Center, according to the study published. They found that more than half the patients could have been cared for in less-expensive and less-invasive settings.
Of the patients in the study, 23.4% were in need of close monitoring but not ICU-level care. Another 20.9% were critically ill but unlikely to recover because they had underlying illnesses or severity of acute illness. For another 8%, death was imminent or the same outcomes were expected in non-ICU care.
In addition, the researchers added up the number of days each of the patients in the study spent in ICU and found nearly 65% of the total number of days those patients spent in ICU were allocated to care that was considered discretionary monitoring, had a low likelihood of benefit despite critical illness, or would have been manageable in non-ICU settings.
Editor’s Note: A version of this article originally appeared in ACDIS’ sister publication, Health Leaders Media. Click here to read the original article.
The 2017 updates to ICD-10-CM included many additions to the digestive system diagnoses, especially with codes for pancreatitis and intestinal infections. The codes largely focus on the lower gastrointestinal (GI) tract, according to an article published in Just Coding. Reviewing the anatomy of the GI tract will likely help coders, CDI professionals, and providers improve their documentation and code selections.
The added specificity in ICD-10 codes lend themselves to more accurate and complete documentation. The updates relating to the lower GI tract are no different. While the added detail can lead to better documentation and quality, it also comes with a need for further and more complete clinical education regarding this body system.
A better understanding of the anatomy of the small intestine, large intestine, the entire lower GI tract, and the pancreas are necessary for correctly applying the codes in the 2017 ICD-10-CM updates. For more information, read the overview, published by Just Coding, here.
by Brian D. Murphy
Last week I had the wonderful opportunity to attend the joint Tennessee Health Information Management Association/Tennessee ACDIS local chapter meeting. The Tennessee Hospital Association kindly hosted the all-day event at their wonderful facility in Brentwood. The theme of the meeting was The Impact of ICD-10 and Payment Reform on Clinical Documentation Improvement.
I have to admit I was a bit nervous as I boarded the plane for the trip, for two reasons:
As it turns out my fears were unfounded. It wound up being a conflict-free meeting in which plenty of concrete strategies for getting CDI and coding on the same page were shared. Some highlights:
Kathy Hallock, RHIA, CDIP, spoke on CDI/coding/quality measures, the three-legged data quality stool. Some wonderful ideas on how these departments interrelate, and how her facility managed to reduce its patient safety indicator rate by 52%.
I also got to network and meet several new people and see some familiar friends, including Sherry Clark, Tom Blanton, Larry Faust, Judy Rochelle, and others. These TN AHIMA and TN ACDIS teams deserve huge credit for pulling together a terrific event. Here’s to many more.
I can now definitively say that bringing CDI and HIM/coding specialists together—and ACDIS and AHIMA together under the same roof—is a wonderful thing. And I managed to avoid the bull, too.
Special thanks to CDIMD Physician Champions and Healthcare Resource Group (HRG) for their sponsorship of the event.
The following is a list of upcoming events are various local chapters:
February
March
Save the date
Look who’s going to the 10th Annual ACDIS conference in Las Vegas! Edna I Betances-Harold, CDIP, CCDS, CCS, of UF Health Shands Hospital and Academic Health Center, won the jackpot thanks to the Florida ACDIS Chapter community. Florida chapter members pay annual dues to help defray costs of their quarterly meetings and every year, one lucky member gets a special raffle prize – a ticket to the ACDIS conference!
