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Managing Medicare Advantage HCCs through Auditing and

Education

Managed Care Compliance Conference

HCCA – February 2012Scottsdale, AZ

Speaker

• Gloryanne Bryant, RHIA, CCS, CCDS

Regional Managing Director HIM

– Revenue Cycle, Kaiser Permanente

– Oakland, CA

– Gloryanne.h.bryant@kp.org

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Disclaimer

• This material is designed and provided to communicate information about clinical documentation, coding, and compliance in an educational format and manner. The author are not providing or offering legal advice, but rather practical and useful information and tools to achieve compliant results in the area of clinical documentation, data quality, and coding.

• Every reasonable effort has been taken to ensure that the educational information provided is accurate and useful. Applying best practice solutions and achieving results will vary in each hospital/facility and clinical situation.

Goals/Objectives

• Gain knowledge of a hospital HCC auditing process

• Learn how to provide quality education on HCC compliance

• Understanding the documentation and coding issues and learn some best practices

• Computer Assisted Coding (CAC) technology for retrospective hospital auditing

• Benefits of CAC to gain accuracy and compliance

• Documentation Improvement and revenue opportunities

• Summary

• Q&A

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Hospital HCC auditing process

• Usually manual process

• Paper world creates dependencies and expense

• Electronic health record helps to drive greater access and efficiencies which can lower cost

Overview: Coding Challenges

• Streamline the EHR work queues

• Workqueue are automatically prioritized by complexity

• Need a tracking system so “No Charge is Left Behind”

• Need an audit system to balance charge tickets to bank deposits

• Must Eliminate backlogs

• Decrease days in A/R

• Increase clean claims and decrease denials

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Overview: Coding

• Medical or clinical coding is very labor intensive and time consuming

– Paper and electronic – volume of text and content

• During the coding process or reading of the medical record information can be missed; information that is useful and valuable to collect

– 2-3 mins per hospital ancillary encounter/visit (lab/rad)… reduced to 20 secs?

– 15-20 mins per hospital inpatient discharge … reduced to ….?

• Impact of poor clinical data collection/coding can be huge and wide-spread

Overview: Documentation

• The Medical Record:

• The collection of information concerning a patient and his or her health care that is created and maintained in the regular course of care.

• Medical Record shall contain sufficient, accurate information to identify the patient, support the diagnosis, justify the treatment, document the course and results, and promote continuity of care among health care providers.

• The information may be from any source and in any format, including, but not limited to print medium, audio/visual recording, and/or electronic display.

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Overview of the Medical Record – Concise and Accurate Information

• Discharge summary, including Discharge or final diagnosis and disposition.

• Initial diagnostic impression. • Problem List (outpatient records only). • Emergency Department record Allergy records. • Advance Directives (if applicable). • Medical History including, as appropriate:

immunization record, screening tests, allergy record, nutritional evaluation, psychiatric, surgical and past medical history, social and family history, and for pediatric patients a neonatal history.

• Physical examination. • Consultation reports. • Physician Orders including those for medication,

treatment, prescriptions, diet orders, lab, radiology and other ancillary services.

• Progress notes • Concise and accurate record of nursing care

administered. • iii. Record of pertinent observations including

psychosocial and physical manifestations and relevant nursing interpretation of such observations.

• iv. Name, dosage and time of administration of medications and treatment. Route of administration and site of injection shall be recorded if other than by oral administration.

• v. Record of type of restraint and time of application and removal.

• vi. Record of seclusion and time of application and removal. (NPH)

• Graphic and vital sign sheet. • Results of all laboratory tests performed. • Results of all X-ray examinations performed. • Consent forms for care, treatment and

research, when applicable. • Problem List (outpatient records only). • Emergency Department record. • Anesthesia record including preoperative

diagnosis, if anesthesia has been administered.

• Operative and procedures report including preoperative and postoperative diagnosis, description of findings, technique used, and tissue removed or altered, if surgery was performed.

• Pathology report, if tissue or body fluid was removed.

• Written record of preoperative and postoperative instructions.

• Labor record, if applicable. • Delivery record, if applicable. • Physical, Occupational and/or respiratory

therapy assessments and treatment records, when applicable.

• Patient/Family Education Plan • Discharge Instructions• Physician Office Notes

What is CAC?

• Computer Assisted Coding (CAC) technology automatically generates codes directly from clinical documentation.

• Computer/engine will “read” electronic text or handwritten documentation AND provide the tentative ICD-9-CM code(s) ready for validation.

• Leveraging: – Computer-based intelligence (systems)

– Natural Language Processing (NLP)

– EHR/EMR

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Hot Healthcare Topic

Research Article from 2008

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CAC

• AHIMA has defined Computer-Assisted Coding (CAC) as use of computer software to "read" clinical documentation and automatically generate medical codes for review and validation by a trained human coder.

• Not all computer tools to assist coders can be classified as CAC. For example, a tool that uses decision trees to help a coder select codes will not meet the AHIMA definition of CAC.

• The distinguishing feature of CAC is that the computer reads the chart text and comes up with a set of suggested diagnosis and/or procedure codes. – The coder's role then changes from a data entry role to a

validation/audit role, checking and approving the CAC codes.

Natural Language Processing (NLP)

• Artificial intelligence is used to extract pertinent data and terms from a text-based document and convert them into a set of medical codes

• “History of cancer” means the patient does or does not have a personal or family history of cancer: by analyzing the context and semantics of the rest of the sentence the NLP engine will apply artificial intelligence to the CAC engine, which then provides the ICD-9-CM code(s).

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Structured Input

• Based on the use of drop down menus that contain clinical terms.

• Structured input for CAC is most commonly seen in the physician office setting. The clinician uses a hand-held computer system to document his or her visit. As the clinician points and clicks on words and phrases, sentences and paragraphs are created. Diagnoses and procedures that should be coded are automatically identified and mapped to the correct clinical code.

Codeable context or Non-codeable context

• How does the computer know what text can be used for code assignment?

• Natural language processing (NLP)

• Language patterns and algorithms

• Statistically predicts and learns to emulate

Read, abstract and comprehend electronic text

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What about “Content”?

• In the EHR world or in a situation where the provider (user) creates the narrative this can be ideal.

• Improved content can change the code assignment and the reimbursement

– Enhancement of payment

– Improved clinical data

• Some CAC products include an application to address poor content and to enhance it.

– CAC content can be delivered to the physician at the point of care with some CAC products

– Eliminates dictation and transcription costs

Benefits of CAC

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Capabilities & Benefits of CAC• Ability to quickly find‚ review and verify electronic health

record (EHR) documentation

– Saving time

• Improves code capture for reimbursement (key documentation)

– Positive financial impact

• Improves case mix index (CMI)

• Expedites the coding process

– Improves DNFC (Discharge not final coded)

– Improves coding accuracy via edits/flags within CAC

Automated systems replace manual coding processes that are tedious and time consuming.

Capabilities & Benefits of CAC (con’t)

• Potential improvement in coding productivity

• Reduces coding overtime and contract support

• Leverages ICD-10 Education and Training

• Utilizes within CDI (Clinical Documentation Improvement) - Concurrent

• Expedites retrospective auditing

– RAC defense

• Creates a Compliance audit trail

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Imagine this …

“getting it right the first time”,

thereby eliminating rework and re-

bills”

What a concept!

Capabilities & Benefits of CAC (con’t)

• Helps to leverage EHR technology

• Documentation enhancement

• Educational enhancement

• Focuses on different payment methodologies– MS-DRG

– APR-DRG (SOI and ROM)

– CPT for CCI edits

– Medicare Advantage/HCC

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MedQuist Study with NLP… Improved Productivity (ER

Records)

CAC Benefits Summary

• Productivity

• Accuracy

• Consistency

• Reimbursement

• Traceability/tracking

• Compliance/Risk

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Barriers or Disadvantages

• Electronic text is ideal

– Versus written

• Interface with your EHR

– Internet, security

• Change & Fear

• Cost

• Implementation & resources

• ICD-10 looming

Healthcare Settings for CAC & EHR

• EHR is ideal– EHRs with an embedded clinical terminology

• All settings:– Inpatient

– Physician office

– Hospital Outpatient Surgery – Facility and Professional

– Hospital Emergency – Facility and Professional

– Hospital Radiology & Pathology CAC specifically (simple Dx coding)

– Rehab

– SNF

– Any settings which requires coding

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CAC Technology

• Usually there is an HL7 feed to send data between systems

• Another option is to use existing interfaces offered by vendors to allow integration with their products.

– The transfer process is completely transparent and controlled by your facility.

Sample CAC view: Reads the electronic text

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Sample CAC View: Text is hi-lighted for auditor/Validator to confirm codeable

Inpatient CAC: Diagnosis and Procedures can be identified in the EHR text

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Outpatient CAC: Diagnosis & CPT

Simple CAC Workflow Overview

Vendor Data Center

STORAGE

NLP Engine

EHR System Other Clinical Systems

Free Text Processor

Knowledge Base

Structured Text

Processor

Coder/Evaluator

User reviews, validates,

accepts/deniesCoding and

documentation

Firewall

Firewall

End User

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Assumptions

• Need an assessment of current coding workflow

• Need to start with the simplest setting?

• Secure Funding and Budget

– What is the ROI? (est.)

• Develop implementation roll out plan

• Engage change leaders

• Engage key stakeholders in vendor selection

• IT and EHR team availability to meet timeline

• Develop implementation plan and roll-out – Pilot

• Track return on investment

Computer Assisted Coding (CAC) technology for retrospective hospital

auditing

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Background with CAC –Retrospective Auditing Project

• 2009 began looking at CAC technology vendors– AHIMA

• 3M™ Computer Assisted Coding demo in March 2010

• A-Life demo in May 2010– Using NPL engine to read text– Prior MA/HCC work with physician side

• Decision made to provide vendor 1000 MA IP Charts as a test (from the prior year Medicare Adv)– Results were positive– Decision made to expand retro auditing

CAC – Retrospective Auditing Project

• The initial 1000 IP charts had results that were positive with many false-positives– IP is not programmed to be “free-standing” so IP is not specific

– Reviewed false-positives• Diabetes Mellitus (DM); Cancer (Pers Hx, Family Hx, etc.)

• DVT vs prophylactic treatment to prevent DVT

• CAC Retooling recommendations made to decrease the false positives– Audited results

• Began MA 2009 inpatient HCC Recapture with CAC– Using external auditors to validate finding and then QA auditors

to confirm and finalize

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CAC – Retrospective Auditing Project

• A total of 21,380 MRNs were CAC reviewed– Medicare Advantage

• Focus to capture Dx documented but not coded for 2009

• 1450 identified– Greater than $6 million

• Identify physician query opportunities– 537 identified– Greater than $2 million potential

• Audited and QA on CAC • Cost: ~ $880,000

Note: prior year all manual auditing, with CAC 15-20% productivity improvement

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Coding Summary by Period

*Inactive members at the end of 2010 have been removed.Coded Only represents the actual net new findings during this initiative

** These are benefit dollars – takes into consideration same benefit % as last year (93%), patient dates of expiration and HCC hierarchy.

Coded

Period Value HCC Count MRN CountTotal MRN Reviewed

P1 (5/7 - 5/14) $ 95,471 21 21 328

P2 (5/15 - 5/21) $ 501,077 118 109 2482P3 (5/22 - 5/28) $ 140,144 32 30 535P4 (5/29 - 6/4) $ 323,464 75 71 1751P5 (6/5 - 6/11) $ 425,137 100 90 2006P6 (6/12 - 6/18) $ 495,110 112 99 1659P7 (6/19 - 6/25) $ 746,175 166 144 2046P8 (6/26 - 7/2) $ 611,453 127 111 1725P9 (7/3 - 7/9) $ 418,243 96 90 1129P10 (7/10 - 7/16) $ 694,737 154 140 1827P11 (7/17 - 7/23) $ 569,486 136 125 1467P12 (7/24 - 7/30) $ 625,437 143 137 1729P13 (7/31 - 8/6) $ 673,774 160 155 1823P14 (8/7 - 8/13) $ 411,604 94 89 1335P15 (8/14 - 8/20) $ 301,818 78 73 909P16 (8/21 - 8/27) $ 315,701 74 73 1573

Total $ 7,348,832 1,686 1,557 24324

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Physician Query Opportunity Summary by Period

Query Only represents the actual net new query opportunities identified during this initiative. Please note that auditors were not asked to review thoroughly for query opportunities.

** These are benefit dollars – takes into consideration same benefit % as last year (93%), patient dates of expiration and HCC hierarchy.

Query

Period Value HCC Count MRN CountTotal MRN Reviewed

P1 (5/7 - 5/14) $ 16,961 4 4 328P2 (5/15 - 5/21) $ 65,826 19 19 2482P3 (5/22 - 5/28) $ - 0 0 535P4 (5/29 - 6/4) $ 36,242 10 10 1751P5 (6/5 - 6/11) $ 20,498 7 7 2006P6 (6/12 - 6/18) $ 46,218 10 10 1659P7 (6/19 - 6/25) $ 49,917 16 16 2046P8 (6/26 - 7/2) $ 48,021 13 13 1725P9 (7/3 - 7/9) $ 80,257 20 18 1129P10 (7/10 - 7/16) $ 158,257 40 39 1827P11 (7/17 - 7/23) $ 241,171 63 60 1467P12 (7/24 - 7/30) $ 367,397 95 84 1729P13 (7/31 - 8/6) $ 363,230 87 80 1823P14 (8/7 - 8/13) $ 168,891 42 38 1335P15 (8/14 - 8/20) $ 163,090 36 35 909P16 (8/21 - 8/27) $ 221,954 60 57 1573

Total $ 2,047,931 522 490 24324

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Top 10 HCCs (Coded Only)

** Takes into consideration patient dates of expiration and HCC hierarchy.

2010HCC Count % Description

79 463 27.5%Cardio-Respiratory Failure and Shock

108 101 6.0%Chronic Obstructive Pulmonary Disease

131 80 4.7%Renal Failure

80 75 4.4%Congestive Heart Failure

31 73 4.3%Intestinal Obstruction/Perforation

92 71 4.2%Specified Heart Arrhythmias

21 62 3.7%Protein-Calorie Malnutrition

105 62 3.7%Vascular Disease

83 49 2.9%Angina Pectoris/Old Myocardial Infarction

100 46 2.7%Hemiplegia/Hemiparesis

2009HCC Count % Description

79 225 11.3%Cardio-Respiratory Failure and Shock

19 131 6.6%Diabetes without Complication

83 109 5.5%Angina Pectoris/Old Myocardial Infarction

105 101 5.1%Vascular Disease

131 100 5.0%Renal Failure

80 85 4.3%Congestive Heart Failure

92 74 3.7%Specified Heart Arrhythmias

82 69 3.5%Unstable Angina and Other Acute Ischemic Heart Disease

157 68 3.4%Vertebral Fractures without Spinal Cord Injury

21 63 3.2%Protein-Calorie Malnutrition

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Top 10 HCCs(Based from 2010 and Compared to 2009 Results – Coded Only)

** Takes into consideration patient dates of expiration and HCC hierarchy.

CAC and Physicians

• Establish positive working relationships with physicians

– build trust and credibility

– create a supportive presence

• Establish positive working relationships with HIM coding professionals

– foster collaborative collegial interactions

– foster a climate of mutual trust and respect

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Documentation Improvement and revenue opportunities

• Physician query

• Documentation Improvement

• Coding improvements and education

• Rebilling or data resubmission

Use Your Results

• Education

• EHR changes

• Reaudit

• Re-education

• Prepare for ICD-10

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Communication is Vital to Quality

• Communication is vitally important to the quality of medical care.– Poor communication can create

misunderstandings, which can result in:

• loss of mutual trust

• wasted time and money

• detriment to patients' health

• Good communication increases doctors' professional satisfaction and sense of purpose.

Quality education on HCC compliance

• Develop specific educational programs

• Non-leading education

• Facts and example

• Target coding and nursing staff

• Clinical documentation improvement (CDI) staff

• Physicians

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HCC 2: SIRS/SepsisSIRS •Due to non-infectious process (i.e. pancreatitis, trauma,

burn)•Must have 2 or more of the following: fever or abn low temp, tachycardia, tachypnea, leukocytosis or leukopenia, elevated bands,

Septicemia •DOES NOT EQUAL SEPSIS•DEF: Systemic Disease assoc w/presence & persistence of pathogenic organisms or their toxins in the blood•Requires positive blood culture and fever

Sepsis •Systemic infection•Must have 2 or more of the following: fever or abn low temp, tachycardia, tachypnea, leukocytosis or leukopenia, elevated bands, •Must also have documentation of an “infection”•The TYPE of underlying infection needs to be documented

Severe Sepsis •Systemic infection•Sepsis with associated acute organ failure and/or lactate level >2

Septic shock •Severe Sepsis with hypotension

HCC 2: Documentation Considerations: Sepsis and Septicemia

• MD specifically needs to document the underlying organism if known

• MD specifically needs to document if it is “Septic Shock”, “SIRS”, “Organ Failure”, etc.

• Document WHEN patient developed sepsis present on admission (POA or during admission)

• A code for sepsis or septicemia is assigned only when the physician makes a diagnosis of sepsis or septicemia.

• Negative or inconclusive blood cultures do not preclude a diagnosis of septicemia in patients with clinical evidence of the condition.

• If the documentation indicates urosepsis and no further information is available, it is defined as UTI. Clarify diagnosis of UTI with clinical indicators of sepsis.

• When a patient has urosepsis and it appears that the UTI has progressed to a systemic infection, query for “septicemia” if the documentation does not support sepsis/SIRS.

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Septic Shock• Septic shock is severe sepsis with

hypotension.

• Documentation for Septic Shock:� Document septic shock if presentseptic shock if present

� Document the underlying infection if known� Identify organ dysfunction if known

• Example: Sepsis due to pneumonia with septic shock and acute renal failureSepsis due to pneumonia with septic shock and acute renal failure

Infection

Pancreatitis

Trauma

Burn

SepsisSevere Sepsis

Septic

Shock

SIRS

HCC 79: Hypoxemia/Hypoxia• Clinical Definition:

• Hypoxemia – Deficient oxygenation of the blood

• Hypoxia – A reduction in the oxygen supply to tissue below physiological levels despite adequate perfusion of the tissue by blood

• Hypoxia is a clinical diagnosis that is captured based on a provider's clinical assessment.

• There are NO CLINICAL CRITERIA necessary to capture this diagnosis.

• Note: Documentation that states the patient is “hypoxic” will result in “hypoxemia” being coded.

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HCC and Diagnosis Focus Areas

HCC Condition Body System / Disease Group

2 Sepsis (w/ pneumonia), SIRS, shock, and UTI

Infectious Disease

7 Metastatic Cancer (all) Neoplasm

10 Cancer: Prostate, Breast, Colorectal and other cancers and tumors

Neoplasm

15 Diabetes w / CKD or PVD Endocrine / Nutrition & Metabolic

16 Diabetes w / Neuropathy and other manifestations

Endocrine / Nutrition & Metabolic

21 Protein Calorie Malnutrition (type/degree)

Nutrition & Metabolic

79 Respiratory Failure (all) & Hypoxia Respiratory System

104, 105 PVD (with and without Complication) Vascular System

131 Renal Failure/disease (include dialysis

status)

Renal / Urinary system

Develop Physician Query Plan/Process

• Follow compliance guidance

• Look at AHIMA Practice Brief on Physician Querying

• Develop forms or templates

• Engagement

• Education and awareness

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Next Steps

• Documentation and coding quality is a must = audit

• Investigate use of CAC technology

• Conduct a pilot

• Develop a project plan and performance improvement

• Engagement Physicians and HIM

Summary

• Complete, accurate, timely documentation is a challenge

• Auditing is useful

• Investigate CAC technology

• Engage physicians

• Use your results and provide education

• Continuous improvement

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Review this Report ….

Questions/Answers

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References/Resources

• Computer-assisted coding: the secret weapon; Mark Morsch Health Management Technology

• ProVation Medical• 3M™ CAE• Dolbey.com• A-Life.com• Coderyte.com• AHIMA.org• AHIMA Practice Brief; Delving into Computer Assisted

Coding• MedQuist, he Impact of Computer-Assisted Coding,

Focus: Coder Productivity and Roles, 2005, White Paper

AHIMA – Practice Brief

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