"Stayin' Alive" in today's healthcare market: Bettering your observed to expected mortality rates
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Transcript of "Stayin' Alive" in today's healthcare market: Bettering your observed to expected mortality rates
Terri Adell, RN, MS, CNRN, CCM
Clinical Documentation Specialist Supervisor
Stony Brook University Medical Center
Catherine Morris, RN, MS, CCM, CMAC
Executive Director of Care Management
Stony Brook University Medical Center
"Stayin' Alive" in today's healthcare market: Bettering your observed to expected mortality rates
Stony Brook University Medical Center
591-bed academic medical centerLevel 1 trauma center
Regional stroke center, neuroscience institutePediatric emergency room
Comprehensive psychiatric emergency room Burn center
Located in Stony Brook, Long Island, NY> 30,000 inpatient discharges/year
Objectives
• Define severity of illness and risk of mortality
• Discuss the risks and benefits of the current public reporting systems
• Describe how to develop a mortality review program
• Understand the benefits of using a risk-adjusted system
• Describe some of the intricacies of coding certain patient types
Current Issues in Healthcare
• High cost of services, push for reform and cost containment
• Change to severity-based reimbursement
• Decreased revenues due to MS-DRGs and RAC initiatives
• Public access to physician/hospital report cards/outcomes
• Change to ICD-10
New Focus: Risk Adjustment/Quality
• Clinical documentation improvement programs initially focused on capturing major complications and comorbidities (MCC) and complicating conditions (CC) that impacted the DRG and that resulted in higher utilization of resources and higher reimbursement
• SBUMC now uses a four-level subclass of APR-DRG data, which more accurately defines a patient’s severity of illness and risk of mortality:– Level 1: Minor– Level 2: Moderate– Level 3: Major – Level 4: Extreme
Benefits of Using a Risk-Adjusted System
• Provides a higher level of specificity about the patients’ condition and the care/treatment provided
• Improve facilities’ quality data
• Improve physicians’ and hospitals’ public report cards
• Enhance revenue, impact LOS
• Ensure regulatory compliance
• Avoid retrospective audit “money recovery” and penalties
CMS Severity Levels
• MS-DRGs introduced October 1, 2007, to better account for severity of illness and resource consumption of Medicare beneficiaries
• There are 3 levels of severity based on secondary diagnosis codes:1. MCC (major complication/comorbidity), highest level
of severity
2. CC (complication/comorbidity)
3. Non-CC does not significantly affect severity of illness and resource use
Definitions of SOI/ROM
• Severity of illness:
The “extent of physiologic decompensation or organ system loss of function experienced by the patient” (HCPro)
• Risk of mortality:
Likelihood patient will die from this illness
The ratio of the SOI to the ROM = Mortality index
SOI ≠ ROM
• Although severity of illness and risk of mortality are highly correlated for many conditions, they often differ because they relate to distinct patient attributes
Acute choledocholithiasis (acute gallstone attack)
Severity of illness is major (level 2)(because of organ system dysfunction)
Risk of mortality is minor (level 1)
• If a more serious diagnosis presents, severity of illness and risk of mortality may increase – e.g., patient develops peritonitis as a complication of choledocholithiasis:
Extreme (level 4) severity of illnessMajor (level 3) risk of mortality
Reasons for Mortality Reviews
• Identify adverse events, errors
• Prevention and process improvement
• Documentation of core measure elements
• Improve O/E severity of illness & risk of mortality
• Revenue capture
• Public reporting
Public Reporting Sites
CMS’ Hospital Comparewww.hospitalcompare.hhs.govU.S. News & World Reportwww.healthgrades.comThomson-Reuterswww.100tophospitals.comLeapfrog Grouphttps://www.leapfroghospitalsurvey.org
UHC (University Healthsystem Consortium)https://www.uhc.com
Premier, Inc.www.premierinc.com/quality-safety/tools-services/performance-suite/clinical-
advisor.jspState governments/DOH _______.govIn New York state:Myhealthfinders.com or NYSDOH.gov
Problems With Public Reporting
• No standard data collection methods
• Diverse data sources
• Provider editing ability
• Timeliness
• Intent
• Relevance, methodological rigor
• Different measures of quality, inconsistent definitions used, different reporting periods
• Institutional variability in the definitions
Improving Standardization
Error- Prone Collection Methodology
• Because mortality measures are obtained through claims rather than clinical data, we must work to improve the standardization of documentation and coding that drives mortality rates
Potential Problem
Overcoding• There is always the risk of hospitals
overcoding, either intentionally or unintentionally, and skewing results
• Disclaimer: The information, techniques, situations, and references in this presentation are for information purposes only. They are not communicated with reference to any specific issue, do not constitute legal or clinical advice, and are not in any way a substitute for such due diligence inquiries and investigations as otherwise may be required by law or clinical standards. Laws, regulations, clinical standards, and other professional due diligence requirements vary from state to state. It is your responsibility to check with your compliance department before using any of the information/techniques from this presentation.
Our Mortality Review Processand Documents
Initially
• Estimated yearly mortalities: 600
• Estimated reviewed records: 50 per month
• One documentation specialist assigned to mortality review per week
• Project length: Three months
Mortality Review Process– Documentation Improvement
• Mortalities coded by HIM• Record “GROUPED” for severity and mortality risk by
coder and second attestation printed and given to coding supervisor
• Each mortality record placed on “MQ” bill hold (if it is a SMART chart, it will be placed on “MR” bill hold as usual until the record is reviewed by the coding supervisor and will then be changed to “MQ”)
• Chart sent to tech park for scanning by coder• Report on mortalities run by coding supervisor daily to
be picked up by CDS with attached attestations• Assigned CDS reviews records daily (Mon–Fri)• No query identified, coding supervisor notified to
removeMQ bill hold by CDS
Mortality Review Process– Documentation Improvement
• Queries identified, physician contacted regarding query by CDS
• If physician does not agree, coding supervisor notified to remove MQ bill hold by CDS
• If he or she agrees, physician documents on HIM retro query form
• CDS brings retro query form to coding supervisor• Appropriate coding changes are made by coding supervisor
and an attestation is sent as a priority scan to tech park • Chart regrouped for severity and mortality risk• Bill hold removed• CDS maintains database to be sent to coding supervisor by
e-mail by close of business every Thursday for reconciliation• Report run every month on changes to severity and mortality
Patient name
Patient enc #
Age
Admitting dx
Attending
Service
Unit
Readmit within 30 days
Admit date
Date of death
LOS
Day of week of death
Time of death
Rapid response
Date/time of code blue
Cause of death
Palliative care
Hospice
DNR/DNI
MCC already coded
CC already coded
New MCC
New CC
Coder DRG
CDS DRG
ROM
Comments
Identified Opportunities
• Data collection
• Neonates
• Short-stay deaths
• Palliative care/“V” code
• Assigning an attending
PATIENT NAME
ENCOUNTER NUMBER
AGE 81 89 92 70 86
ADMITTING DX subdural hematoma chf Intracerebral hemorrhage breast cancer copd
ATTENDING Alpa Desai William Lawson Riyaz Kamadoli Ostrow Stavola, Thomas
SERVICE MCU CAD GMX MOL CAD
UNIT MICU 17s CCU 16n 19N CCU
READMIT WITHIN 30 DAYS no no no yes no
ADMIT DATE 3/21/2010 3/31/2010 3/31/2010 4/2/2010 3/17/2010
DATE OF DEATH 3/24/2010 4/12/2010 4/3/2010 4/8/2010 3/27/2010
LOS 3 days 2 3 6 10
DAY OF WEEK OF DEATH Wednesday Monday Sat Thursday Saturday
TIME OF DEATH 2127 0220 1PM 0309 2220
RAPID RESPONSE no no no no no
DATE/TIME OF CODE BLUE 3/21 & 3/24 (2105) na na no
CAUSE OF DEATH cardio pulm arrest/sepsis Septic shock Intracerebral hemorrhage metastic breast ca anoxic brain injury
PALLIATIVE CARE no no yes yes yes
HOSPICE no no no yes no
DNR/DNI no yes yes yes yes
MCC ALREADY CODED yes no no yes yes
CC ALREADY CODED yes no no yes yes
NEW MCC acute resp failure multiple no acute resp failure
NEW CC chronic sys. Chf see comments no no
CODER DRG 85 293 64 374 246
CDS DRG 280 64 374 246
ROM 3 2 4 3 4COMMENTS Retro query acute resp
failure with agreement. Review of chart revealed multiple mccs not capture because no attending cosign. Retroqueried Dr Lawson in person who wrote on retroquery: "Non STEMI, cardiogenic shock w multiorgan system failure, renal, respiratory, gastrointestinal, cerebral"
Retroquery for acute resp. Failure based on freq documentation of
resp distress w sats low 80s. Retroquery signed
by attending
Financial impactnone $5,102.00 none
New ROM 4 4 4
Neonates
New York State Law
• If there is documentation that the infant “drew a breath,” then the child must be encountered as a live birth and considered an inpatient mortality..
Definition of Stillbirth
• A stillbirth is when a fetus that was expected to survive dies during birth or during the last half of pregnancy*
*In the United States, the term stillbirth or fetal demise does not have a standard definition.
For statistical purposes, fetal losses are classified according to gestational age.
A death that occurs prior to 20 weeks' gestation is usually classified as a spontaneous abortion; those occurring after 20 weeks constitute a fetal demise or stillbirth.
Many states use a fetal weight of 350 g or more to define a fetal demise.
More Confusion
New York
vs.
California
• However, not all states interpret the weeks of gestation in the same manner.
• In California, 20 weeks' gestation is worded "twenty utero gestational weeks" and has therefore been interpreted to be 23 weeks from the last menstrual period. (Implantation in the uterus does not occur until 1 week after fertilization.)
• In New York state, intrauterine fetal death (IUFD) includes a death at a gestational age of 20 completed weeks or greater, or if fetal weight is 300 g or more.
Neonates
• When are neonatologists/pediatricians involved?
• Under what week gestational age are they coded solely from the obstetrician's notes?
• Neonatologist language– Apnea vs. acute respiratory failure
Short-Stay Patient Deaths
• There are many difficulties to address:– Medical history
– Assessment is focused on the problem
– Etiology
– No/incomplete diagnosis
– “Unresponsive”
– Lack of studies or clinical findings
– Lack of indication for procedures
– Who is the attending of record?
Short-Stay Patient Deaths
• A 57 y/o patient was brought in as a Code H from an outside hospital s/p cardiac arrest and intubation. He underwent emergent stenting upon arrival. He was clearly extremely ill, and his death in the CCU within 24 hours of arrival was not unexpected.
• This patient was coded as having a ROM of 1 (the lowest risk in a scale from 1–4).
Short-Stay Patient Deaths
• The sickest patients who arrive as a code H and expire rapidly and only have a slim chart may end up with the lowest ROM if the right verbiage is not stated by an attending physician or NP. – Cardiac arrest should be queried for cardiogenic
shock
– Intubation as acute respiratory failure
– Renal insufficiency as acute renal failure
– Glasgow coma scale of 5 must be stated as coma
MORTALITY REVIEW QUICK REFERENCE
DX OR INFO PRESENT DX INCREASING RISK OF MORTALITY
Renal insufficiency, elevated creatinine Acute renal failureSOB, increases respirations, respiratory distress, increases O2 demand Acute respiratory failure
Obtunded, unconscious ComaUnresponsive to verbal or tactile stimuli, pupils & dilated Coma
Positive tropinins, no EKG changes, demand ischemia NSTEMI
Ascites, pleural effusion Ascites, pleural effusion secondary to…malignancy
Cardiac arrest Cardiogenic shock, acute respiratory failure
Cardiac arrestPulmonary insufficiency secondary to shock/trauma
Increases ammonia levels with ams in liver dz Hepatic encephalopathyIncreasing liver enzymes in pt with cirrhosis, liver mets, etc. Liver failure
SAH, SDH, ICH, CVA, head trauma Cerebral edema, brain edema
Pneumonia Aspiration pna, gm neg pna, fungalIncreased WBC, hypotensive on vasopressors, bacteremia Septic shock
Cath Notes
Palliative Care
• Comorbidities
• Lack of specific treatment
• Palliative care – V667
• Top 9 diagnoses
• DNR code – V49.86
V66.7 Code
• Effective October 1, 1996• Terminally ill patient receiving palliative care• Palliative care is an alternative to aggressive
treatment – the focus is toward management of pain and symptoms
• Care provided is dependent on the terminal illness• Always a secondary code – terminal condition is
always the principal diagnosis• Comfort care, end-of-life care, and hospice care are
synonymous terms• MD documentation must include these or similar
terms
Hospice or Palliative Care Code Usage
UHC CMS Hospital Compare
U.S. News & World Report America’s Best Hospitals
Thomson-Reuters 100 Top Hospitals
HealthGrades
Admitted from a hospice
No Yes, if Medicare benefit used in last 12 months
No No No
Palliative care code v66.7 excluded?
No No No Yes Excluded in 12 dx-based cohorts
Risk adjusted
Yes No Yes NA/No NA/No
Necessary position to be applied
Any Top 9 (within top 25 this year)
Top 9 Top 9 Top 9
Assign anAttending Physician
Mortality Progress Note
• Improve documentation
• Clarify cause of death
• Include other diagnoses
• Ensure attending is identified
MortalityNote
Case Study
Attestation
Clinical documentation specialist queried for further clarification of primary diagnosis based on documentation of unresponsiveness and GCS of 5.
Physician documented that the patient was in a coma secondary to large intracranial hemorrhage and cerebral edema. This increased the SOI and the ROM to 4.
Case Study
This patient underwent CPR in the ED with futile outcome. Because of documentation of prior cardiac interventions et al., the SOI/ROM increased to 4/4.
Results
MonthSBUMC % observed
SBUMC % expected SBUMC index NYS index UHC index
January 2.55 2.76 0.92 1.03 0.91February 2.43 2.75 0.88 1.00 0.83March 2.30 2.80 0.82 0.93 0.80April 2.43 2.75 0.88 0.87 0.79May 1.83 2.56 0.72 0.91 0.81June 2.62 2.76 0.95 0.93 0.79July 2.33 2.65 0.88 0.94 0.80August 1.95 2.56 0.76 0.92 0.80September 3.14 3.04 1.04 0.94 0.80October 2.07 2.68 0.77 0.98 0.82November 2.49 3.07 0.81 0.96 0.79December
Excludes implant of heart assist system; heart, liver, and lung transplants; neonatology; normal newborn; obstetrics; psychiatry; and rehabilitation product lines.
Discharge month% deaths (observed) % deaths (expected) Mortality index
2010-012.01 2.29
0.88
2010-021.86 2.22 0.84
2010-03 1.68 2.29 0.73
2010-041.81 2.41 0.75
2010-05 1.41 2.03 0.69
Mortality Observed and Expected
O/E Index
Severity of illness andrisk of mortality are highly dependent on the patient's underlying clinical problems
Terri Adell [email protected] Morris [email protected]
Hughes J. 3M Health Information Systems (HIS) APR™-DRG Classification Software—Overview. In Mortality Measurement. February 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/mortality/Hughessumm.htmThe History of Medical Coding
John Landers, eHow Contributor. Mortality Rates as a Measure of Quality and Safety, “Caveat Emptor” Robert Klugman, MD,1, Lisa Allen, PhD,2, Evan M. Benjamin, MD,3, Janice Fitzgerald, MS,4, and Walter Ettinger, Jr., MD, MBA1 American Journal of Medical Quality OnlineFirst, published on January 21, 2010 as doi:10.1177/1062860609357467
Evaluation of Fetal Death Author: James L Lindsey, MD, Consulting Staff, Department of Obstetrics and Gynecology, Santa Clara Valley Medical Center; Assistant Clinical Professor, Department of Obstetrics and Gynecology, Stanford University School of MedicineCoauthor(s): Sultana L Sultani, MD, Resident Physician, Department of Obstetrics and Gynecology, Santa Clara Valley Medical CenterContributor Information and Disclosures Updated: Jan 18, 2011
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