Welcome to UASI’s Lunch and Learn: CDI Management Series We … · 2021. 2. 24. · Welcome to...
Transcript of Welcome to UASI’s Lunch and Learn: CDI Management Series We … · 2021. 2. 24. · Welcome to...
Welcome to UASI’s Lunch and Learn: CDI Management Series We will begin shortly.
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UASI CDI/UR Service Line Stats
▪ 4 out of 5 UASI clients request ongoing or return services following an initial CDI engagement
• UASI works for top hospitals utilizing our experienced team of consultants to deliver value tailored to our client’s specific needs
• CONSULTANTS average 8 years in CDI and/or UR, and 22 years in clinical nursing
• MANAGERS average 11 years in CDI and/or UR and 24 years in clinical nursing
UASI CDI/UR Services
Ten Key Steps to Successfully Implement
Outpatient CDI in a Physician PracticeStaci Josten, BSN, RN, CCDS
Director, CDI/UR Services, United Audit Systems, Inc.
Feb 2021
Desired Outcomes
At the end of this presentation, attendee will be able to:
• Understand the benefits of implementing outpatient CDI in a physician practice
• Explain the steps to initiate outpatient CDI in a physician practice
• Identify important keys to each step of implementing a successful Outpatient CDI program in physician practice
Polling Question
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Does your organization currently have an Outpatient CDI Program?
1. Yes, it’s going great
2. Yes, it’s in the pilot phase
3. Yes, but we need help
4. Not now, but planning in the near future
5. No, we don’t have any plans for an OP CDI Program
Benefits of Physician Practice Outpatient Clinical Documentation Improvement
• Accurate ICD 10 Code Assignment • Code assignment directly impacts hierarchical condition category (HCC)
assignment, which will impact the patient and population risk adjustment factor (RAF)
• Complete documentation of supported diagnoses (not just service levels)
• Appropriate reimbursement
• Accurate quality scores
• Reduction in denials
Assess Current State
• Identify areas of opportunity. Examples:
• Denial rates, RAF scores, Quality scores• Comprehensive Assessment to include:
• Investigate all documentation & coding processes• Baseline patient record review • Evaluate HCC data over 2 years• Case selection based on data-driven criteria
Assess Current
State
Define & Align
Set Program Goals
Determine ROI
Staffing Infrastructure
Define Workflow
Communicate, Educate
Performance Expectations
Monitor Track
Ongoing Evaluation
Key to Step #1: Understand where issues exist
Patient Chart Review Tips
• Targeted approach to find opportunities
• Longitudinal risk-adjusted patient audit (not individual claims or encounters)
• Includes an evaluation of both documentation and final coding of HCC conditions on all claims in the current year for each patient
• Identify documentation and/or coding gaps
• Pre and post-review RAF score comparison
Compliant HCC Capture
HCC Change Opportunity Description Type
Diagnosis Documented – not coded Potential claim update; Diagnosis identified in health record but not reported on the claim
Coding
Diagnosis documented – more specified code supported
Potential claim update; Diagnosis identified in medical record, appears a more specific diagnosis is appropriate
Coding
Documentation supports dx – either not explicitly documented or not coded
Potential query opportunity; Information in the health record (clinical indicators) supports adding additional diagnosis if the physician agrees and documents more
specifically
CDI
Diagnosis coded – MEAT not found in health record
Potential query opportunity; Diagnosis identified in health record but no documented evidence of monitoring, evaluating, assessment, or treatment. Physician would need to further expand documentation for this diagnosis to be coded and reported on a claim
CDI
Outpatient CDI Audit Findings Example
ICD10CMCode Code Description
CMS-HCC Model Category
V24 HCC RAF ScoreFrequency of Occurrence in Potential HCC Changes
E6601 Morbid (severe) obesity due to excess calories 22 0.250 50
F320 Major depressive disorder, single episode, mild 59 0.309 28
F339 Major depressive disorder, recurrent, unspecified 59 0.309 24
E1165 Type 2 diabetes mellitus with hyperglycemia 18 0.302 20
N183 Chronic kidney disease, stage 3 (moderate) 138 0.069 18
J449 Chronic obstructive pulmonary disease, unspecified 111 0.335 8
E1122 Type 2 diabetes mellitus with diabetic chronic kidney disease 18 0.302 6
Potential HCC Changes Impacted 154
200 Patient Outpatient CDI Audit, 200 patients reviewed, 154 patients with opportunity77% of patients with HCC opportunity
Define Program Scope and Approach
• Determine scalable approach and reporting structure
• Define areas of focus for CDI efforts, for example:
• High volume, high revenue patients
• Members of specific health plans
• Primary care providers vs. certain specialties
• Start with a few area(s) for proof of concept and then refine and expand
Assess Current State
Define &
Align
Set Program Goals
Determine ROI
Staffing Infrastructure
Define Workflow
Communicate, Educate
Performance Expectations
Monitor Track
Ongoing Evaluation
Key to Step #2: Determine initial area(s) of focus
Approaches• Selective Pre-visit review
• Specific doctors, clinics or specialties
• By visit type (e.g. annual visits, post-op appointments)
• Members of specific health plans (e.g. MA, ACOs)
• Identify and communicate documentation gaps, problem list redundancy/gaps
• During the visit (the day of the visit)• Address identified documentation gaps with provider
• Physician interactions/training (curb-side, at-the-elbow, skype and/or telephone calls)
• EHR diagnosis capture mechanisms
• Post-visit “back-end” processes• Close the loop – HCC work queues
• Code capture on the claims
• Provider reviews to share for educational purposes
Outline Goals and Ongoing Data Needs
• Determine data available and future data needs
• Align data collection formats to measure outcomes
• Set clear, measurable goals
Assess Current State
Define & Align
Set Program
GoalsDetermine ROI
Staffing Infrastructure
Define Workflow
Communicate, Educate
Performance Expectations
Monitor Track
Ongoing Evaluation
Key to Step #3: Define the goal(s) and data needs based on assessment results and benchmarks
Data Analytics Examples and Tip
Code Comparison
Year Over Year Comparison
Use Disease Registries
Data Analysis Tip
• Narrow down patient populations to decrease volume of data to analyze
• Example: Select patients alive, enrolled in a risk adjusted plan, seen at least once by family practice or internal medicine
Determine Return on Investment
• Tactic to gain administrative support
• Demonstrate financial impact of RAF scores
• Lag time in RAF score reporting
• Extrapolation of chart review findings
• Specific to the patient population based on prevalence
Assess Current State
Define & Align
Set Program Goals
Determine ROIStaffing
InfrastructureDefine
WorkflowCommunicate,
EducatePerformance Expectations
Monitor Track
Ongoing Evaluation
Key to Step #4: Determine way(s) to calculate financial impact
No Diagnoses RAF Score
Incomplete Documentation RAF Score
Complete Documentation RAF Score
76‐year‐old female,Community, Aged
76‐year‐old female,Community, Aged
76‐year‐old female,Community, Aged
Dual Full Benefits 0.593 Dual Full Benefits 0.593 Dual Full Benefits 0.593
CKD Stage 4 (HCC 137) 0.260 CKD Stage 4 (HCC 137) 0.260
Heart failure (HCC 85) 0.371 Heart failure (HCC 85) 0.371
Diabetes (HCC 19) 0.107 Diabetes w/renal complications (HCC 18) 0.340
Hemiplegia (HCC 103) 0.487
BKA status (HCC 189) 0.795
DM + HF + CKD 0.379 DM + HF + CKD 0.379
RAF 0.593 RAF 1.710 RAF 3.225
Estimated annualpayment
$5,550 Estimated annualpayment
$16,006 Estimated annualpayment
$30,203
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CMS-HCC Examples
Example of Financial Impact Extrapolation
Morbid Obesity (HCC 22) Population Example:
• 1500 of the patients in the ACO have BMI > 40
• 500 of these patients had a claim with a code for morbid obesity submitted (E66.01)
• 1000 patients did not have morbid obesity coded in 2020
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Potential Missed HCCs RAF Score for HCC 22 CMS annual base rate POTENTIAL Opportunity
1000 patients X 0.250 x $9366 = $2,341,500
Example of Potential Financial Impact
UASI Out patient CDI Audit Example
Average of Facility RAF 2020 Score
Average of UASI RAF Score
Average RAF Score Variance
1.0994 1.2374 0.1380
Patients with RAF Changes
Sum of Facility RAF 2020 Score
Sum of UASI RAF Score
Variance in Pre and Post Audit raw RAF
CMS-HCC model CY 2020, relative factor annual base rate for
all segments
Potential Annual Increase in Risk-
adjusted Reimbursement
872 921.99 1121.85 199.86 $ 9,366 $ 1,871,926**
**For this number to be realized, patients must be seen by provider, HCC documented/supported, and coded
Develop Staffing Infrastructure
• Program Leadership• HCCs & risk-adjusted payment knowledge
• CDI & coding knowledge
• Staff qualifications and reporting• Clinical expertise and coding expertise
• Establish staffing ratios• Determine number of clinics and providers
Assess Current State
Define & Align
Set Program
GoalsDetermine ROI
Staffing Infrastructure
Define Workflow
Communicate, Educate
Performance Expectations
Monitor Track
Ongoing Evaluation
Key to Step #5: Form the initial team and team structure
Initial Staffing Recommendations
• Start with Pilot and work to expand to other providers and clinics
• Suggested Outpatient CDI Duties
• Streamline current pilot project work flow for pre-visit review process
• Review Risk adjusted payer patients during annual physicals
• Provide monthly education to assigned clinics and providers
• Assist in Post-Visit/Pre-Bill Work Queue and query providers as needed
• Initiate provider documentation audits
Define Initial Workflow & Processes
• Establish processes and procedures
• Insert CDI within the clinic workflow
• Resist the urge to mirror IP CDI process
• Leverage EHR functionality
Assess Current State
Define & Align
Set Program
Goals
Determine ROI
Staffing Infrastructure
Define Workflow
Communicate, Educate
Performance Expectations
Monitor Track
Ongoing Evaluation
Key to Step #6: leverage current workflow, tools and staff
Outpatient CDI Process ExampleCDS Pre-Visit Review for
Targeted Visits
• Annual physical/ wellness visits
• Possible targeted diagnoses in the future
• Reviews conducted 1-2 weeks in advance
• Focus on Medicare Advantage and other risk-adjusted payers
• Goal of 25-30 new reviews per day
• Develop communication plan/query process for providers to know which chronic conditions should be addressed
Provider Engagement and Education
• Assign Outpatient CDS to Physician Practices
• Divide Practices/Providers per CDS (approximate 8 practices per current 3 CDSs)
• 1-2 clinic visits per week per CDS for site education and provider one on ones
• Complete documentation reviews on Providers
• Assign up to 50 provider chart audits per month per CDS to review results with Providers
• Complete feedback on reviews and opportunity for review for assigned providers
Post Visit and Pre Bill
• Create work queue in EHR for Pre Bill Review by CDSs and possible HCC Coder
• Examples of work queue holds:
• Depression unspecified
• CKD unspecified
• BMI > 40 without diagnosis of obesity or morbid obesity
• CDS will retrospectively query provider as needed
• CDS will maintain a monthly summary of bills held and corrected conditions, by practice and provider
Polling Question
For the first 6 steps we just discussed, what area do you feel is (or would be) the most challenging for your organization?
1. Assessing current state
2. Defining & aligning the Outpatient CDI Program
3. Setting program goals
4. Determine return on investment
5. Staffing infrastructure
6. Defining workflow
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Communicate & Educate
• Identify key stakeholders and all key players
• Communication plans
• Messaging to each audience
• Goals, timelines, progress, outcomes
• Education plans
• Be brief, use real examples
Assess Current State
Define & Align
Set Program
GoalsDetermine ROI
Staffing Infrastructure
Define Workflow
Communicate, Educate
Performance Expectations
Monitor Track
Ongoing Evaluation
Key to Step #7: Get information to the right people at the right time
Provider Tip Sheet Example
Set Staff Performance Expectations
• Set clear staff performance expectations
• Everyone working toward the same goal
• Conduct time studies
• Develop realistic productivity goals
• Evaluate/adjust throughout the process
Assess Current State
Define & Align
Set Program
GoalsDetermine ROI
Staffing Infrastructure
Define Workflow
Communicate, Educate
Performance Expectations
Monitor Track
Ongoing Evaluation
Key to Step #8: Communicate realistic expectations to staff
Outpatient CDI Staffing Expectations Example
Goal Range
Number of Assigned Providers
Number of Assigned Clinics
Number of Pre Visit Patient Reviews
Number of Post Visit Reviews
Number of Provider Audits
Goals will vary widely among organizations depending on the multiple variables
Monitor, Track , Measure
• Identify both process oriented and outcome oriented measures
• Record specific improvements• Actual and potential improvements
• Case level information
• Individual staff productivity
• Analyze trends, evaluate outcomes
Assess Current State
Define & Align
Set Program
Goals
Determine ROI
Staffing Infrastructure
Define Workflow
Communicate, Educate
Performance Expectations
Monitor Track
Ongoing Evaluation
Key to Step #9: Identify KPI’s to monitor and analyze
Outpatient CDI Metric Tracking Example
Ongoing Program Evaluation
• Continue to evaluate the impact
• Reflect and refine program goals
• Continuously adjust approach to respond to evolving insights and changing priorities
• Periodic audits/QC to verify accuracy and consistency
Assess Current State
Define & Align
Set Program Goals
Determine ROIStaffing
InfrastructureDefine
WorkflowCommunicate,
EducatePerformance Expectations
Monitor Track
Ongoing Evaluation
Key to Step #10: Remain flexible, adapt, incorporate new ideas
Summary of Ten Key Steps To Successfully Implement Outpatient CDI in a Physician Practice
1. Understand where issues exist
2. Determine initial area(s) of focus
3. Define the goal(s) of the program and establish data needs of the program
4. Determine way(s) the program will show ROI
5. Form the team and team structure
6. Define initial workflows and processes
7. Outline comprehensive communication plan
8. Identify and communicate expectations to staff
9. Establish key performance indicators you will want to monitor and analyze
10. Evaluate process to identify additional opportunities and ways to gain efficiencies
Join us for the next
UASI CDI Management Series :“Outpatient CDI HCC Clinical Concepts”
March 24, 2021
email: [email protected] for inviteuasisolutions.com | 31
Download the 2020 Passport to HCC’s on our UASI Solutions Website
http://marketing.uasisolutions.com/passport-to-hccs-fy19
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Questions ?
UASI CDI/UR Services
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UASI CDI/UR Services Stats
▪ 4 out of 5 UASI clients request ongoing or return services following an initial CDI engagement
• UASI works for top hospitals utilizing our experienced team of consultants to deliver value tailored to our client’s specific needs
• CONSULTANTS average 8 years in CDI and/or UR, and 22 years in clinical nursing
• MANAGERS average 11 years in CDI and/or UR and 24 years in clinical nursing
UASI at a Glance
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Headquarters:
Founded:
Clients:
Team:
Charts handled annually:
Solutions:
Experience
• Management: 22 years of HIM experience;
11 in CDI
• Coding staff: 8+ years
Quality
• 97% accuracy in coding
• 100% target for accuracy, certification and
meeting industry standards
Reliability
• 32+ years in business
• 40 clients in US News & World Report best
regional and honor roll hospitals
Culture
• People-centric, team-driven culture
• High employee satisfaction
• 20% new hires referred from current employee
• Industry-leading average employee tenure
Cincinnati, Ohio
1984
200+ hospitals/health systems nationwide
450+ employees, including AHIMA/AAPC-certified
coders, HIM and clinical documentation specialists
3.75 million coded; 200,000 audited
Coding Services, Coding Reviews, Clinical
Documentation Improvement, Revenue Integrity,
HIM Solutions, Strategic Consulting