Developing quality indicators for in-patient post-acute care
Patient Safety Indicators: Focus on Documentation
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Patient Safety Indicators: Focus on Documentation Megan Cortazzo, MD – UPMC Medical Director, Clinical Documentation Improvement and Health Information Management Kelly Gates, RN, MHA, CCDS – Strategic Product Manager, Optum360 i 2 • Identify how physician documentation can impact the reporting of Patient Safety Indicators • Discuss the impact on workflow at the University of Pittsburgh Medical Center to ensure the accurate reporting of Patient Safety Indicators • Review and discuss medical scenarios which illustrate how different departments identify Patient Safety Indicators • Apply learned concepts to explore potential opportunities at your hospital Objectives
Transcript of Patient Safety Indicators: Focus on Documentation
Patient Safety Indicators: Focus on Documentation
Megan Cortazzo, MD – UPMC Medical Director, Clinical Documentation Improvement and Health Information Management
Kelly Gates, RN, MHA, CCDS – Strategic Product Manager, Optum360
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• Identify how physician documentation can impact the reporting of Patient Safety Indicators
• Discuss the impact on workflow at the University of Pittsburgh Medical Center to ensure the accurate reporting of Patient Safety Indicators
• Review and discuss medical scenarios which illustrate how different departments identify Patient Safety Indicators
• Apply learned concepts to explore potential opportunities at your hospital
Objectives
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Adverse Patient Events
• 64% more likely to use long-term care
• 2.8 times more likely to die within 90 days
• 30% more likely to be readmitted within 90 days
• Cost for caring were 40% higher
• $224 million of the total 90-day expenditures for all elderly Medicare
http://www.ahrq.gov/downloads/pub/advances/vol1/Encinosa.pdf
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• Patient Protection and Affordable Care Act (PPACA) of 2010 (Obamacare) implemented several new Medicare programs intended to improve health care quality, using “pay-for-performance” payment strategies
• CMS uses claims data to identify and incentivize hospitals to report patient outcomes
• CMS implements quality initiatives to assure quality health care for Medicare Beneficiaries through accountability and public disclosure
Hospital Quality Overview
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Hospital Acquired Conditions: Progress to date
• Penalties incurred are less than the cost of implementing additional safeguards to avoid the penalty
2010-2013
145-121 HACS per 1,000
discharges
HAC rate reduction 9%
decline
50,000 fewer deaths
$12B Healthcare costs were saved (1)
2014
121 HACS per 1,000
discharges
Plateau
(1) https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/qualityinitiativesgeninfo/downloads/cms-quality-strategy.pdf(2) https://www.hfma.org/Content.aspx?id=44309
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• Hospitals with a Total HAC score in the worst 25% quartile will have payment reductions
• Impacted 724 hospitals for CMS FY 2015
• Hospitals receive 99% of the amount of payment after adjustments:
1. Base DRG payment adjustments are calculated (DSH, uncompensated care, IME)
2. Add-on payments
3. Hospital Value Based Purchasing penalties
4. Readmission Reduction penalties
Hospital-Acquired Condition Reduction Program (HACRP)
Source: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2014-Fact-sheets-items/2014-12-18-2.html
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It’s a Team Approach
Quality Physician Coder CDIS Compliance
• Minimal knowledge of coding guidelines
• Aligned with CDC definitions
• HAI Abstracts measures
• Knows exclusion and inclusion rules
• Minimal knowledge of coding guidelines
• Unaware of documentation impacts to quality
• Doesn’t have time
• Expert at cause and effect
• Codes by provider documentation
• Productivity requirements
• Limited medical cause and effect scenarios
• Just too many!
• Understands medical cause and effect scenarios
• Can identify potential cases concurrently for quicker clarification
• Minimal coding knowledge
• Ensures compliant practices
• Monitors organizational risk
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The Patient Safety and Adverse Events Composite
http://www.qualityindicators.ahrq.gov/News/PSI90_Factsheet_FAQ_V1.pdf
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UPMC Overview
• Megan Cortazzo, MD – Medical Director, CDI and HIM, UPMC
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UPMC Overview
$11 billion integrated global health enterprise
Western PA’s largest employer
60,000+ employees
22+ academic, community, and regional
hospitals 5000+ licensed beds
280,000+ inpatient admissions
185,000 surgeries performed annually
3.9 million+ outpatient visits
710,000 emergency visits
40+ UPMC Cancer Centers
180 affiliated oncologists
UPMC Health Plan: 2.7 million total
members network
500+ doctor offices and outpatient sites
5700 affiliated physicians (3600
employed by UPMC)
Region’s largest network of rehab services
70+inpatient, outpatient and LTC facilities
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The Struggle is Real!
Exclusion Criteria
Coders live in black and white world
Quality department are experts on HACs/PSIs VBP but not coding requirements Lack of
physician understanding
of industry requirements
Barrage of questions, and
requests for case reviewBalancing act:
financial vs. quality
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• Leverage the expertise from each group and work together.
• Conduct regularly scheduled meetings.
• Ensure representation from quality, CDI, coding, compliance, physician advisor.
• Perform evaluation/validation of quality-of-care issue requiring a complication code.
Solutions to the Struggle
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HAC/PSI Review Workflow
Patient admitted: CDI
begins
Patient discharged:
coding performed
DRG Specialists
perform post-coding review
All cases with HAC/PSI
trigger post-coding edit
(Used to be Medicare only)
Quality reviews
cases/places cases for
group review in joint
sharepointworklist
DRG Specialists re-
review case for coding
accuracy and additional exclusion
opportunities
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What Happens Next?
Problematic cases set aside for group
discussion
• Discuss cases.• Add exclusion codes if
applicable.• Discuss need for query.• Remove code if not accurate
or alternative code may be used.
Weekly QA, Coding and CDI
Conferences • Involves groups sharing their expertise with coding requirements/coding clinics, AHRQ exclusions, Comorbidity Risk Adjustment.
Education
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WHY Exclusion Criteria is so important* (ICD-9 vs ICD10)
Exclusion Criteria and Risk Adjustment
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Understanding Exclusion Requirements and Comorbidity Risk Adjustment
PSI 9: Perioperative Hemorrhage or Hematoma Rate.
• Exclusions• D696 thrombocytopenia,
unspecified• D68.9 coagulation defect
unspecified
Examples of ICD-9 Impacting Comorbid conditions.
**ICD-10 TBD
• Weight Loss• Renal Failure• Peripheral vascular
disease• Obesity
• Focus on exclusion areas can have an major impact on reported rates• ** Currently, we do not know the ICD-10 Comorbid conditions. AHRQ is
still analyzing codes and impact for this year.
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• Some conditions will reduce the impact of a Patient Safety Indicator.
• In ICD-9 examples include conditions such as malnutrition, alcohol abuse.
• At times those conditions may not be coded because a DRG is maximized. They may not impact revenue directly, but may do so indirectly by preventing a penalty from CMS.
• Engage your quality team to be aware of those conditions.
• With ICD-10 AHRQ is gathering data to determine the list of Diagnosis that can risk adjust. Currently no risk adjustment is being performed.
Comorbidity Risk Adjustment
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Case Examples
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• Patient with a history of being on Coumadin for a-fib. This was documented in the Vascular Surgery note.
• He was noted to be coagulopathic and was given FFP prior to removal of a R femoral groin temporary dialysis catheter.
• Immediately after removal, the medical team noted pulsatile bleeding.
• Pt taken emergently to OR for control of active bleeding.
Case Example – PSI 09 Peri-operative Hemorrhage/Hematoma
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• OR report stated:“Patient had arterial bleeding from a hole on the anterior medial side of the proximal right SFA where the previous temporary dialysis catheter had passed directly through the artery and into the adjacent right CFV.”
• QUALITY REQUEST: “Would it be appropriate to consider this condition POA-Y? Appears as though bleeding would have occurred whomever removed the line based on the placement of the line per the OR report.”
Case Example – PSI 09 Peri-operative Hemorrhage/Hematoma
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• ANSWER: Patient was in the hospital and the line wasn’t removed until there was suspicion of an infection. The bleed wasn’t POA.
Case Example – PSI 09 Peri-operative Hemorrhage/Hematoma
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• Exclusions• We discussed the clear documentation of
the surgeon of being on anticoagulants, coagulopathy and treatment of the coagulopathy.
• We were able to code D68.32 Hemorrhagic disorder due to extrinsic circulating anticoagulants.
• We were able to have this excluded from the PSI.
• Collaboration between quality and coding was essential to the resolution of this case.
Case Example – PSI 09 Peri-operative Hemorrhage/Hematoma
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• Event: Splenic Injury During Abdominal Injury
• Supporting Documentation: Physician documentation of scar tissue in operative note, but he didn’t make a clear connection between the scar tissue and laceration.
• Quality asked:
Due to the notation of scar tissue, was this
unavoidable?
• After discussion, we decided to query the
Surgeon.
Case Example – PSI 15 Accidental Laceration
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• Physician Response:
“In dissecting this away from the spleen, we ended up with a 1X2 cm capsular deficiency in the spleen that was controlled with the argon beam coagulator and Arista. We then sharply dissected the scar tissue where the left adrenal had been. This appears to have been unavoidable due to the dense scar tissue.”
• Also notated by physician that this did not alter or prolong care for the patient.
Case Example – PSI 15 Accidental Laceration
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• During orthopedic surgery a drill bit broke and was left in bone.
• The surgeon documented clearly that retrieval of the drill bit would lead to more injury for the patient.
• QUALITY REQUEST:
• Requested the code be removed since it seemed mechanical and beyond the control of the physician.
Case Example- PSI 05 Retained Surgical Item
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Case Example- PSI 05 Retained Surgical Item
• VOLUME 31 FIRST QUARTER
• NUMBER 1 2014, Page 21
• Update––Foreign Body Left During Surgery, Notice
• Answer: Do not assign code 998.4, Foreign body accidentally left during a procedure, when the provider intentionally leaves a foreign body during surgery as to not subject the patient to the additional risk of removal.
• We did not code 998.4 and added these codes: T81.89XA with addition of Y65.8
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• Exclusion: Delirium, dementia• Documentation:
– Medical Progress Notes March 4th & 5th, “Delirium much improved. NH3 much improved.”
– CCM note: “Patient neurologically appears to have recovered from encephalopathic event.”
– Other notes: Delirium scores present with highest score being 6 on 3/2/16.
• QUALITY REQUEST: Can delirium be coded?
PSI 11: Post Op Respiratory Failure
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• Answer:
– Documentation supports hepatic encephalopathy.
– Delirium indicated by code R41.0 is integral to hepatic encephalopathy
– Code K72.90 added for hepatic encephalopathy.
• In this case, documentation supportive of hepatic encephalopathy and that code supersedes delirium. Based on this, it could not use as an exclusion.
• Our Teams worked together to appealed this to AHRQ. AHRQ wants to review more ICD-10 data before changing exclusions.
PSI 11: Post Op Respiratory Failure
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• All decisions are based on coding guidelines and internal coding guidelines.
• If uncertain, consult coding clinics.
• If a coding clinic doesn’t have an answer related to the topic, we send a question to coding clinic.
• Example: A-lines
• For accidental laceration/punctures, discussion with an impartial surgeon is sought to assist with guidance.
• Use of Chair of Surgical Services.
What Happens When Disagreement Occurs?
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• All reviews tracked:
– Coding education
– Physician non-compliance
– Staff resource utilization
– Financial impacts
• Sharepoint critical for tracking/ streamlining process.
Case Tracking
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Significant Reduction in Reviews by Working Together
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Significant Reduction in Reviews by Working Together
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Significant Reduction in Reviews by Working Together
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• Members:
• Coding
• Quality
• Compliance
• Surgical Resident
• Advanced Practice Practitioner
• eRecord Medical Director
• Medical Director CDI and HIM
• Goal is to work as a team to develop strategies for education on improved documentation, IT solutions to improve clinician workflow.
Future Direction: Documentation Integrity Steering Committee
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