All Entries in the "RACS" Category
Diagnose first, admit second
Consider CDI collaboration with case management to target documentation concerns in the emergency department.
Among other tidbits in my background, I’m a recovering case manager. It’s a hard, often thankless job, and it never ends. I don’t think I could do it again, and I give lots of credit to those who still work in this field. Nevertheless, I have had many occasions to interact with case managers in my previous role as a CDI specialist, and now, a CDI consultant.
As a recovering case manager, I often shied away from dealing with the CM department, but I’ve come to realize that not developing collaborative processes can be a huge mistake. When we avoid case management, we avoid the opportunity to build an ally. We both want medical records that reflect the optimum patient acuity, and that will survive RAC and other audits. And this process starts at the hospital’s front door.
Case managers review patients in the emergency department for admission criteria. If they know that chest pain and syncope and abdominal pain are RAC targets, and that documentation of diagnoses instead of symptoms may move the DRG out of the RAC crosshairs, they can communicate this to the physicians. I like to think of it this way: when the physician writes nothing of consequence, the CDI specialist looks for clinical findings and asks for the diagnosis, while the case manager asks for clinical findings and the treatment plan that support the medical necessity for the admission and strengthen the diagnosis that we just got.
It’s a symbiotic relationship.
I’ve had occasion to work with the case management team at a client hospital, and we decided to put our collective heads together to see how we could educate ED physicians not to admit patients who didn’t meet criteria. We chose as our slogan: “Diagnose first, admit second!”
We created one page flyers to be posted in the ED and distributed to the ED physicians on popular topics such as chest pain and syncope. In the flyers, we briefly gave suggestions of alternative diagnoses, defined what is needed to meet admission criteria, and encouraged physicians to consult with case management before writing that admit order.
At the same time, I’ve been presenting a weekly series of lectures to the case management department, very similar to what I would use to teach a new CDI specialist, but adding a little twist that ties clinical documentation improvement to case management. It’s been a big hit. They are eager to help teach physicians not to write “CHF” or “urosepsis,” and they want to learn more. I’m going to give them all they can handle, including helping them read their PEPPER and use it to their best advantage.
Never assume that because someone doesn’t understand what you do, that they don’t want to understand what you do. It’s like working with physicians and nurses; when you show them how your job relates to them and how it benefits everyone, you get more cooperation. And as we used to say, cooperate and graduate.
MDC 26: Understanding the unrelated
Look everywhere for clinical indicators. You never know where the physician may be hiding them.
In the endless pursuit of bringing order to chaos, I’m going to talk about major diagnostic category (MDC) 26, DRGs 981–989, operative procedures unrelated to the principal diagnosis.
These DRGs are used when the principal diagnosis and the principal procedure come from unrelated MDCs. Some people love them because they often bring higher relative weights and thus higher reimbursement. My own opinion is that they can be a minefield, a ripe target for RAC audits.
Because we want to “marry” our medical and our surgical MDCs, MDC 26 should be the MDC of last resort. (Please read Lynne Spryszak’s blog article “Q&A: Definition of ‘marrying’ DRGs” for an excellent explanation.) It should usually be reserved for those few cases where the physician identified an unrelated diagnosis after admission, and that condition required acute treatment. It may also be used in situations where the correct procedure code, despite being clinically related to the reason for admission, just doesn’t fall into the same MDC as the principal diagnosis.
CDI reviewers should make every effort to make sure that another MDC is not more appropriate. Because of the high relative weight, using MDC 26 is a red flag to auditors that upcoding may have happened. Use of this MDC may lead an auditor to question whether procedures unrelated to the reason for admission were tacked on, procedures that otherwise normally would have been done on an outpatient basis, in order to increase revenue.
Let’s look at an example of an appropriate use of MDC 26 for a patient admitted with chronic obstructive pulmonary disease (COPD) exacerbation. On day two of the admission, while being treated for COPD, she develops chest pain, elevated troponins, and is diagnosed with a myocardial infarction (MI). The physician takes the patient to the catheterization lab and a surgeon performs a percutaneous coronary angioplasty (PTCA).
COPD is MDC 4, respiratory, and the code for a PTCA can only be found within MDC 5, circulatory. The MDCs are unmarried. So in this situation, COPD would be the principal diagnosis, the MI is the MCC, and the DRG assignment is 981, extensive OR procedure unrelated to principal diagnosis, with MCC.
I once reviewed the charts of a Medicare patient who presented with shortness of breath due to acute systolic heart failure, pneumonia, and a non-ST elevation MI (NSTEMI). The patient was taken to the cath lab, and received a PTCA with two coronary stents placed. I chose DRG 246, PTCA with drug eluting stents and an MCC, with a relative weight of 3.1802, in MDC 5. The coder chose pneumonia as the principal diagnosis, taking the DRG to 981, extensive OR procedure unrelated to principal diagnosis, with a relative weight of 5.0634. The coder rationed that the patient presented with shortness of breath, cough, and pneumonia, and actually coded the record that way, at least at first. Then the two of us discussed how big a risk it could be to step outside of the MDC when there were two circulatory diagnoses documented on admission, either of which could meet the definition of principal diagnosis. The coder eventually agreed.
Here is another principle new CDI specialists sometimes have trouble wrapping their heads around: If any billable procedure is performed during the admission that is in the same MDC as the principal diagnosis, you cannot go to MDC 26.
Look at that COPD patient again. Let’s say that after the PTCA, the surgeon performs a closed lung biopsy. A closed lung biopsy is a billable surgical procedure within MDC 4. Therefore, the DRG assignment goes back into MDC 4, and becomes DRG 166, other respiratory OR procedures, with MCC. The patient could have 10 more surgeries and the case will stay in the respiratory MDC. Even if the patient receives a coronary bypass graft, the DRG stays in the respiratory category. Only another surgical procedure that moves the case higher in the respiratory hierarchy, or a pre-MDC procedure, such as a tracheostomy, could now change the DRG assignment now.
I recently completed a PEPPER audit of a hospital’s vulnerable target areas. One of its vulnerabilities was, you guessed it, unrelated OR procedures. I pulled up a random sampling of Medicare cases in those DRGs, and I found that sometimes the DRG fell to MDC 26 because a patient develops complications during or right after an outpatient procedure. AHA’s Coding Clinic for ICD-9-CM (4th Quarter, 2008) states:
“If the reason for the inpatient admission is a complication, assign the complication as a principal diagnosis. If no complication, or other condition, is documented as the reason for the inpatient admission, assign the reason for the outpatient surgery as the principal diagnosis. If the reason for the inpatient admission is another condition unrelated to the surgery, assign the unrelated condition as the principal diagnosis.”
Acute respiratory failure might have nothing to do with an ethmoidectomy, but if it’s the reason they became inpatient, it becomes the principal diagnosis and the ethmoidectomy takes the DRG to 989.
Gotta love those coding conventions! Just think of all the people who spent so much time dreaming them up… and all the CDI and coding professionals who struggle to understand them every day.
WWRD: What would the RAC do?
RAC focus areas need to be on your CDI program's radar screen but it need not take over your program's focus.
There has been much discussion based on what Recovery Audit Contractors (RAC) and other state and federal regulatory bodies are doing or what their next move will be (though does anybody really know?!?).
We’ve all heard the stories of denials of well documented and clinically substantiated conditions; of the role the RAC reviewer incentive structure plays in RAC determinations, of confusing correspondence addresses, etc. Whether or not the stories are true doesn’t matter as much as the attention such stories garner. We’ve also heard of the fear that prevails and this makes me wonder about the effect of these reviews on our day-to-day workflow.
I recommend we stop, take a deep breath, and think…Why not switch our focus from “what would the RAC do” back to what care was provided and how was it documented in the medical record?
Now, I’m not saying we should ignore RAC, or forget that they are there. Believe it or not, they do keep us grounded. I’m just saying let’s try not to make them the focus. Let’s try not to work according to the WWRD principle.
We are currently in the midst of a nationwide movement toward quality and public reporting. It is commendable that our national focus has turned to the quality of healthcare. And providing quality care is all about doing the right thing at the right time. If we stay true to who is at the center of this movement, ‘the patient,’ and set the stage for the right process to ensure that we do the right thing at the right time, good outcomes will prevail.
Let us take that thought and apply it to the world of CDI. The concurrent process of CDI, in and of itself, takes place at the ‘right time,’ while the patient is still in the hospital and we have all the necessary medical record, laboratory, and dietary information available to us. Through our consistent, thorough review of the information contained within the record we can help clarify ambiguous information, identify potentially omitted diagnoses, and ensure the record accurately captures all the clinically relevant care provided.
Although our task can be complicated, we have available to us several documents that assist us in our endeavors to do the ‘right thing:’ ACDIS’ Code of Ethics, AHIMA’s 2008 practice brief, Managing an Effective Query Process, the 2010 document, Guidance for Clinical Documentation Improvement Programs, and their 2010 publication, Clinical Documentation Improvement Toolkit. In order for our day-to-day CDI practices to be able to withstand audit scrutiny we must use these guidances, plus our own facility-specific policies and procedures to guide us.
When we stray from our ethical and moral core, and away from the guidelines in place to protect us, we could find ourselves alone and exposed. There have been several discussions (most recently during the November 17, 2011 ACDIS Quarterly Membership Conference Call) regarding the dangers of leading queries and the potential legal implications involved. We all need to operate within the guidelines and be prepared to stand up and defend the information contained within the medical record.
If we center our attention on doing the ‘right’ thing, focus on our responsibility to the patient, and continue to assist in the precise and complete representation of the patient encounter within the medical record, we will have done our job, and possibly kept the RAC at bay. Let us do what we do best, according to the guidelines, and let the policies and procedures that are in place steer us on the right path.
Don’t think about what RAC would do; think about doing the right thing at the right time for the patient.
Santa’s not the only one watching to see if you’ve been bad or good
Singing: He sees you when you’re sleeping. He knows when you’re awake. He knows if you’ve been bad or
What will the jolly old elf will bring to the RAC offices?
good, so be good for goodness sake.
Remind you of anyone? No? Here’s a hint. It rhymes with knick-knack but these groups aren’t known to be particularly “nice.”
Audit contractors (Recovery Audit Contractors or RACs) are not Santa, but they are watching you, and they certainly know if you’ve been naughty.
Let’s be realistic, all of your facility healthcare data is being scrutinized, analyzed, and compared. Statistical data gives audit contractors an idea of which hospitals fall off the bell curve, and what diagnosis qualify as low hanging fruit.
If your hospital has a 30% sepsis admission rate and all other hospitals in your area have a 10% rate, then you pretty much are going to stand out like a sore thumb. Do not fool yourselves. It is not because your CDI department is that much better at capturing sepsis as a diagnosis.
Take a look at how your facility does business and whether it may be pushing the envelope when it comes to leading queries and creative coding. Does your hospital follow AHIMA’s recommendations when it comes to formulating compliant queries? The brief clearly states that:
“Individuals who perform the query function should be familiar with the AHIMA Standards of Ethical Coding, which direct coders to assign and report only the codes and data that are clearly and consistently supported by health record documentation in accordance with applicable code set and abstraction conventions, rules, and guidelines.”
Next, review and update your own internal policies and procedures. Many hospitals create these policies and then never check to make sure the rules are being followed. The AHIMA guidance states:
“Individuals performing the query function should follow their healthcare entity’s internal policies related to documentation, querying, coding, and compliance, keeping in mind that data accuracy and integrity are fundamental HIM values. Only diagnosis codes that are clearly and consistently supported by provider documentation should be assigned and reported. A query should be initiated when there is conflicting, incomplete, or ambiguous documentation in the health record or additional information is needed for correct assignment of the POA indicator.”
Lastly, create an audit process to ensure that both your own policies and AHIMA recommendations are being followed. Healthcare entities should consider establishing an auditing and monitoring program as a means to improve their query processes. They can consider several methods for this ongoing process. Queries can be reviewed retrospectively to ensure that they are completed according to documented policies. This might include reviewing determining whether the:
- query was necessary
- language used in the query was not leading or otherwise inappropriate
- query introduced new information not otherwise included in the medical record
Based on the results of this review, the healthcare entity may need to identify specific corrective actions. For example, any cases identified as containing inappropriate queries which resulted in inaccurate code assignment will require corrective action and possibly rebilling. Inappropriate queries should be tracked, trends identified, and appropriate education, training, and/or disciplinary action taken when warranted.
No one wants to get a lump of coal in their stocking. And no one wants to give the RAC or other auditor a Christmas bonus. Take time this holiday season to make some New Year resolutions and ensure that your facility is compliant and knowledgeable. You will then reap the rewards of a stocking filled with peace of mind.
AHA report shows 77% of RAC denials overturned
Latest report shows RAC denials are being overturned.
Interesting news bites from the American Hospital Association (AHA)… according to more than 2,000 hospitals responding to the AHA’s latest RACTrac survey, hospitals are appealing nearly a third of all RAC denials and 77% of those were overturned in favor of the provider.
The survey also reveals that medical necessity denials are the top reason RACs have denied claims since first-quarter 2010, and that the majority of these medical necessity denials were for one-day stays found to be in the wrong setting, not because the care was medically unnecessary.
The latest RACTrac report reveals that 57% of hospitals report that they have yet to receive any education related to avoiding payment errors from the CMS or its contractors.
Want to know more? Attend the AHA’s free webinar on January 4 to hear an update on the RAC program and review the survey results. Register at https://www1.gotomeeting.com/register/533318961 . For information, visit http://www.aha.org/advocacy-issues/rac/ractrac.shtml.
Asset or Liability: How do you describe your CDI program?
A recent discussion on the ACDIS CDI Talk list serve provoked me to ponder: Is your program truly an asset
Don't use measuring tape to determine your CDI program success.
to your organization? Does it promote complete and accurate clinical documentation reflective of patient severity of illness (SOI), medical complexity and quality outcomes that justify the costs of care? Or is your program really a liability to the organization?
The CDI Talk discussion asked how programs calculate their return on investment (ROI). One response pointed out that any monthly report of CDI case mix change and financial reimbursement effectiveness must include a disclaimer informing readers about the fact that such data is subject to adjustment for transfer DRGs provisions inherent in the inpatient prospective payment system (IPPS). So, here’s my two-cents on the issues raised.
Another adjustment to consider
An effective CDI program can be a significant asset or a significant liability depending upon how the program is initially structured, set up, rolled out, and carried forward with daily CDI activity. Unfortunately, a majority of CDI programs center their metrics (proof of their ROI) on increased financial reimbursement to the hospital. This takes away from the overall potential of the CDI program for the hospital as well as the physicians. That’s because this narrow focus on reimbursement positions CDI programs as revenue enhancement programs. It forces CDI specialists to focus on the capture of CCs/MCCs and “more specific” principal diagnosis. And this, in turn increases risk and liability for the hospital.
Consider the following common analysis conducted by CDI programs to prove their effectiveness:
- Number of queries left by the CDI
- Number of queries that change the principal diagnosis
- Number of queries that add a CC/MCC
- Number of physician queries responded positively to by the physician
- Number of physician queries not responded to by the physician
- Number of queries left in the record which the physician did not agree to clarify/add documentation
- Potential capture rate of monthly CC/MCC not obtained due to physician disagreement
- Change in monthly case-mix-index
- Time from admission until record was reviewed and DRG worksheet completed
- Average number of times a record was reviewed per admission
While reviewing these statistics can provide insight into a CDI program’s success, commitment to these types of matrices as the sole indicators of a program’s success can stymie a program.
A primary goal of CDI professionals is to improve overall clinical documentation in the record for purposes of accurate, concise, and effective reporting of patient acuity/SOI, physician clinical judgment, medical decision making, and resource consumption through specificity in documented diagnoses.
One of many “by-products” of this stated goal of CDI is that the resulting reimbursement more closely approximates the care provided. However, strict focus on financial reimbursement benchmarks creates incentives for staff to omit queries that don’t affect payment or increase queries for conditions that do. This, ultimately, artificially creates a rosy ROI picture for the CDI program. It also increases financial risks as auditors data mine, down-code, deny, and ultimately take back reimbursement from erroneously documented and coded cases.
Now you see it, now you don’t
In my experience, many a RAC denial is fundamentally related to CDI program deficiencies. Often a query results in the physician documenting a diagnosis in the record just once. The query may have asked the physician to clarify the principal diagnosis, secondary diagnosis, or sought to add a CC/MCC to the record.
These queries frequently include:
- Aspiration vs. community acquired pneumonia
- Sepsis with change in mental status vs. sepsis with acute encephalopathy
- COPD exacerbation with hypoxemia vs. COPD exacerbation with acute-on-chronic respiratory failure
The physician may respond to the query by including the specified diagnosis or diagnoses in his/her next progress note yet not include these same diagnosis specificity in the continued care progress notes and discharge summary. According to our previously discuss benchmarks, the CDI manager counts the physician’s response as a “win,” and moves on to the next chart review.
The physician’s conclusory diagnostic statement without accompanied discussion of pertinent clinical facts and information constitutes insufficient documentation from an “outsider’s review” perspective. The RAC or other third-party payer retrospective reviews frequently down-code or deny these claims due to such documentation deficiency.
Effective CDI programs should incorporate more than financial measures in their program benchmarking. Clinical documentation beyond mere diagnostic conclusory statements supporting clinical presentation of the patient as well as the clinical facts of the case is essential for revenue integrity and continuity of care. Consider the following found in the most recent Statement of Work for the RAC:
“Clinical validation is a separate process, which involves a clinical review of the case to see whether or not the patient truly possesses the conditions that were documented. Clinical validation is beyond the scope of DRG (coding) validation, and the skills of a certified coder.”
Now is an ideal time to consider your answer to the “asset vs. liability” dilemma, take inventory of the processes of your CDI program, and aim for positive process changes in the new year to ensure your program’s contribution to the healthcare organization.
One may wish to determine how many RAC denials were associated with disallowance of principal or secondary diagnoses (CC/MCC) on the basis of insufficient documentation. The continued success of the profession of CDI is predicated upon adapting to changes in the healthcare marketplace. Renewed emphasis on a “visionary” mindset versus complacency will ultimately govern the true success of your CDI program.
A peck of PEPPER, Part 3
Sort through your PEPPER reports to find additional query opportunities.
If you’ve started using your PEPPER to help you identify potential issues at your hospital, good for you! In this final entry, I’m going to suggest you take it a step further—identifying charts that may fail for lack of medical necessity.
I’m pretty sure that a RAC bounty hunter will jump at the chance to overturn your admissions due to not meeting criteria. Nobody’s expecting you to become a case manager, but it behooves all of us to gain an understanding of what documentation may survive a medical necessity audit.
Quite a few of the PEPPER medical necessity target areas involve what might be considered questionable diagnoses—including our old favorites, chest pain, TIA, back pain, and syncope—and some others that you might not have thought of as questionable, such as DRG 314-316 and DRG 393-395, as well as short stays in renal failure, vascular surgery, and heart failure DRGs. If you are a high outlier, review your short stay patients, to see if their documentation supports an inpatient stay.
InterQual(TM) guidelines now include the condition-specific diagnoses of acute coronary syndrome (ACS), asthma, epilepsy, heart failure, pneumonia, and stroke/TIA, with plans to add many more. The new guidelines help you determine who qualifies for inpatient and who should stay in an observation status. If you don’t have access to admission and continued stay criteria, make friends with someone who does, or better yet, ask your manager to give you access and send you to class to learn the basics. (Some hospitals use Milliman (TM) guidelines, so your mileage may vary.)
Your impact will be on documentation that supports inpatient severity of illness. The physician admitting a patient for acute onset chest pain or suspected MI needs to understand the importance of documenting a specific diagnosis such as acute MI supported by positive cardiac markers, or unstable angina, any EKG changes that support the diagnosis, and following specific treatment protocols.
It’s not enough for a physician to diagnose pneumonia in a stable patient—the treatment on day one is the same for both observation and acute inpatient status so the difference is in the presentation, and that means documentation. What is the oxygen saturation? Did the patient fail outpatient antibiotics? Is there evidence of abscess or empyema? Is the pneumonia multilobar? Are there additional clinical risk factors?
For your TIA patients, a TIA lasting longer than 60 minutes raises the likelihood of meeting inpatient criteria. Teach your physicians to assess and document the duration of TIA symptoms. “R/O stroke” won’t allow you to work around TIA, without documentation of specific physical findings consistent with a possible stroke, such as paresis or dysphagia, or confirmation of CVA by CT or MRI. For your stable heart failure patients, among the requirements for an acute inpatient admission is oxygen saturation below 89% or a sustained heart rate of 100-120 bpm within 24 hours of admission. Evidence of greater instability, such as hypotension, mental status changes, or heart rate > 120, with IV medications or increased oxygen requirements, may move the patient into an intermediate or critical care status.
In DRG 314 – 316, other circulatory system diagnoses, you might have patients who come back with a vascular complication such as an occluded central line. Just having a complication is not enough to justify an inpatient stay—is there evidence of a decreased peripheral or femoral pulse? Did they qualify for an inpatient admission in some other way? Syncope, DRG 312, may meet inpatient criteria if it is attributed to a cardiovascular drug, reflects evidence of certain arrhythmias or pacemaker failure, or if the patient has known cardiac disease. Do you see a documentation opportunity there?
Look closely at your short-stay patients, regardless of DRG. Did they meet criteria because they underwent a procedure on the inpatient list? Or did the physician not really think about admission status when they wrote the order? Your PEPPER will list your top medical DRGs for one-day stays. Consider auditing the top DRGs, particularly if they are the non-specific DRGs such as chest pain and syncope, for medical necessity. Can the top DRGs be explained by a specific patient population your hospital services? Did the documentation support the status order? Did the patient leave before the case manager had a chance to review the case? Does your CM department just do a great job of moving patients through the system? What processes does your hospital have in place for reviewing short-stays, either concurrently or retroactively? What documentation improvement processes can you recommend and/or implement?
I was trying to think of some snappy way to join SALT with PEPPER, but all I came up with was the strategic arms limitation talks. So on that note, don’t try to force documentation to fit when it doesn’t. But the more you know, the more you can do.
A peck of PEPPER, Part 2
In my previous entry, I talked about the PEPPER process and how it can be used to help identify
There's no sense crying over spilled PEPPER.
potential issues of errors in coding, billing, or medical necessity that are specific to each hospital. Now I want to review some target areas; specifically, stroke/ICH, respiratory infection, simple pneumonia, septicemia, unrelated operating room (OR) procedures, debridements, and DRGs with CCs/MCCs.
Stroke/ICH patients. What is your usual neuro patient population? Do you treat a large number of stroke/ICH patients, and not so many carotid stenosis or TIA patients? Check your charts to make sure that traumatic brain hemorrhages are documented and coded differently than non-traumatic brain hemorrhages, as they fall into a different DRG grouping. Are you querying when it is unclear? Are you looking at indicators of brain compression and cerebral edema in your radiology reports and then seeking appropriate clinical correlation? Are you erroneously coding brain compression as an MCC on a traumatic brain hemorrhage?
Respiratory infections. This includes aspiration pneumonia, gram-negative pneumonia, and bacterial pneumonia. It also includes cystic fibrosis with pulmonary manifestations, which is a common diagnosis at my hospital. Review records to ensure that the diagnoses are documented correctly and have clinical support. Verify that complex pneumonias aren’t being coded based on a culture report without physician confirmation.
Simple pneumonia. If your facility is in low outlier PEPPER category for simple pneumonias, take a look at patients discharged with a principal diagnosis of COPD. Are there signs of pneumonia that are being missed? I found it instructive to overlay my hospital’s trends in the simple pneumonia group against the trends in the respiratory infections group. There was a consistent inverse relationship. When pneumonia was high, respiratory infections were low, and vice-versa. It made me wonder if we’ve been seeing the same number and type of patients, but diagnosing them or coding them differently.
Septicemia.The percentage in the septicemia group compares diagnoses in the sepsis medical DRGs against the diagnoses in the kidney and UTI DRGs. If your facility is a high outlier in this target area look at your sepsis cases, especially ones with sepsis due to UTI to be sure that sepsis was documented and coded correctly. If the physician is writing “urosepsis” and there is clinical evidence of systemic sepsis, are you determining if it is UTI or sepsis due to UTI? Is it being coded with sufficient clinical support? Is a “septic” patient going home in one or two days? If your facility is a low outlier, ask the same question. Are you encouraging the physician to document sepsis due to UTI, rather than urosepsis, when there truly are clinical signs of sepsis?
Unrelated OR procedure. This includes anything that falls into MDC 26, procedure unrelated to principal diagnosis. We already know this is automatically a red flag, so if your facility is a high outlier, meaning a high percentage of your total OR cases are coded into DRG 981-989, you need to take a long, hard look at those cases to be sure the DRG assignment is legitimate. Granted, there are some situations in which the procedure and the diagnosis really are medically related but the codes just don’t fall into place in the same hierarchy. You can rule those out pretty quickly when you audit charts in DRG 981-989.
Excisional debridements. Debridements are fun because you have to involve your surgeons or wound care physicians. (Fun like root canal work, I’m thinking.) You don’t want your facility to be a high outlier if excisional debridements documentation isn’t really that strong. Make sure your operative and procedure notes follow the coding guidelines to the letter before allowing that 86.22 code to go out. You don’t want to be a low outlier because you might be missing excisional debridements that really were performed. Grab any charts with an ICD-9 CM code of 86.28 (nonexcisional debridement) as principal procedure, especially with a medical DRG, and find out why excisional debridements aren’t being performed or aren’t being correctly documented or even aren’t being correctly coded. In my review, I found cases where the debridement certainly looked excisional, but nobody asked the surgeon or podiatrist. I even found one (and it was mine originally, but now I’ve got that 20-20 hindsight going) where the physician documented that he used a portable curette down to the subcutaneous tissue base, removing all the devitalized unhealthy tissue. Sounds like it could have been an excisional debridement to you? It did to me, too, but what stopped me dead in my tracks was the dictated consult which read, “Nonexcisional debridement was performed.” It wasn’t until I was auditing the chart months later that it hit me: the physician almost certainly dictated, “AN excisional debridement was performed,” the transcriptionist heard it as NON-excisional debridement, and nobody fixed it or asked about it, including yours truly. Ouch!!!
DRGs with CCs or MCCs. I would be worried if my facility were a low outlier on this one. While CCs/MCCs are not my mission in life, nevertheless as a CDI specialist I do expend a significant amount of effort on capturing allowable co-morbidities; if my hospital were below 80% of other hospitals, I’d wonder if I might be missing something. Are charts not being reviewed? Are queries not being asked? Do physicians pull when I push? Is coding reluctant to code certain diagnoses or certain types of documentation? I would be looking at process. Co-morbidities aren’t just about reimbursement; they have a major impact on severity of illness and risk of mortality scores. If I were a high outlier, I’d be worried, too. I’d seriously pull some charts and drill into any chart coded with a single CC/MCC to make sure they’ll stand up to government and payer scruitney. Actually, even if you’re not high or low, reviewing charts with single co-morbidities is not a bad habit to start, if you’re not already doing it.
Remember to look at your 12-quarter trends. If you see steady change in a positive or negative direction, or big inconsistencies from one quarter to the next, think about what might be happening at your hospital. Perhaps there are system changes or sudden turnover. If you’re a teaching hospital, do you see a dip when the new house staff come on board? If you focus improvement efforts on a target area, decide what you can impact, determine how much time you’ll realistically need to see a meaningful change and look for evidence of that improvement in a later PEPPER.
One more entry to go. I’ll finish up this series with a discussion of medical necessity target areas, and what we can do with them and for them.
A peck of PEPPER, Part 1
Peter Piper picked a peck, how about your CDI program? Have you taken a peek at your PEPPER?
My analytical side is always harassing me to get it more involved in what I do. So I decided to dig into our hospital’s PEPPERs. PEPPER is the Program for Evaluating Payment Patterns Electronic Report, issued quarterly. (Calling it a PEPPER report is like calling an ATM an ATM machine; it comes from the department of redundancy department.) The acronym ST-PEPPER stands for short term acute care hospitals’ PEPPER.
Glenn Krauss previously provided a good overview of PEPPER both here on the ACDIS Blog and through his contributions to an article in the April 2011 edition of the CDI Journal. While I have been aware of PEPPER for some time, I did not have access to our reports until fairly recently. And, to be honest, PEPPER can be a little intimidating. You need to become familiar with what the reports tell you and then you have to be comfortable doing a little digging into your own facility data after you’ve reviewed the reports.
I really recommend that a new user of PEPPER become comfy cozy with the user guide provided by PEPPER Resources. You might discover that it’s not really that difficult to learn, and if you love to crunch numbers and analyze information the way I do, it’s almost fun.
If you don’t understand percents versus percentiles, now is the time to learn it. For areas that PEPPER identifies as potential risks for audit, your report will give you a percentage, based on a numerator/denominator. The numerator is always the targeted DRGs, and the denominator is a larger base of DRGs.
So if you are looking at the stroke/intracranial hemorrhage target area, the numerator is the number of cases in DRG 61-66 (CVA/ICH with or without thrombolytics), and the denominator is DRG 61 – 69 (all of the above, plus carotid disease and TIAs). Let’s say your hospital had 20 cases in DRG 61-66; that would be the numerator. Your facility had 80 cases in DRG 61-69, so 80 would be the denominator. So the ratio would be 20/80 or 1/4 or 25%. That is your percent.
Now PEPPER takes your percent and compares it to the percents for hospitals in your state, in your Medicare Administrative Contractor/Fiscal Intermediary (MAC/FI) jurisdiction, and in the nation. The percentile is where your hospital falls among its peers. If your facility percent is higher than that of 75% of the hospitals in the nation, your national percentile is 75%. If your percent is lower than the percent held by 75% of the hospitals in the nation, your national percentile is 25%. If that’s still too confusing, the PEPPER Resources website offers tutorials.
PEPPER focuses on what it calls “outliers,” hospitals whose percentile is above 80 or below 20. Hospitals whose percentile is above 80 (remember, their percent is higher than 80% of hospitals in the group) are high outliers. Hospitals whose percentile is below 20 (their percent is lower than 80% of hospitals in the group) are low outliers. For many of the target areas, PEPPER recommends facilities with high outliers review their charts for overcoding, and low outliers for undercoding.
The Office of the Inspector General (OIG) is tasked to detect and prevent fraud, waste, and abuse, improve economy and efficiency, and hold accountable those who do not meet requirements or who violate the law. Among the numerous focus areas in the 2012 OIG Work Plan, (which is a document that outlines the OIG target areas for the coming year) is Medicare inpatient and outpatient payments—to be evaluated by reviewing hospitals that are the most risky and the least risky, as determined by data analysis. It’s fascinating reading.
So when you get your PEPPER, which is an Excel spreadsheet, the first thing you should see is your “Compare” page. On the Compare page, you will get an overview of each target area, with numbers specific to your hospital, for the last reported quarter of data.
What I like to do is go through it and highlight all the targets in which my hospital is a high or low outlier for either national, jurisdictional, or state. (National is most important, followed by jurisdictional, then state.) Then, I scrutinize those target areas, pull cases in those target DRGs, and review them for coding accuracy and clinical documentation support.
But PEPPERs include 12 quarters worth of data, so evaluating trends is important. After the Compare page, there is a tab for each target area, followed by a tab with a line graph of the hospital’s percentiles for the previous 12 quarters, if data is available. So maybe this quarter we were just under the 80th percentile, but for the previous 11 quarters, we were above. Should I look at this target? Yes, I think so.
Don’t assume that because your hospital is a high outlier for a given target, that automatically means there’s a problem. There may not be. You may trigger as a high outlier for stroke/ intracranial hemorrhage (ICH) because you are a stroke center and receive a large number of referrals for stroke/ICH. You may trigger as a high outlier for 2-day stays in heart failure because your hospital aggressively follows core measures, and you’ve got a great relationship with the nursing home next door and the home health agency across the street–so you get your patients out quickly. Nevertheless, I would still do a random audit of cases in those DRGs to protect your facility against potential audit risks.
At the same time, I would also not assume that because your hospital is a low outlier for a target area, that you are free and clear.
You want your medical records to reflect the most accurate severity of illness, intensity of services, and resources expended, and too many low outliers might mean you’re not capturing those variables effectively. Working with your report will give you an enhanced awareness of what areas are particularly vulnerable to scrutiny, and so all the target areas should gather your attention. Look at what processes are working well, and try to apply them across the board.
In my next entry, I will discuss some of the target areas and talk about strategies for using PEPPER to its best advantage. Happy hunting!
Complete and accurate clinical documentation is the future of healthcare
What can you can do to improve your program? How can you put some of your CDI strengths into better practice and re-examine your
Hospitals need to get their clinical documentation in order now.
weaknesses to determine what you can do to tweak it and make it a more successful program? There are numerous opportunities for program improvement every day. Let’s look at a few of the common areas of CDI program improvement begin practiced today.
For many years, many programs were driven by what we did from a Medicare and reimbursement perspective. When you look at what is currently best practice in the documentation world, it really is about addressing documentation for more than just financial issues. We want to make sure that we capture the true severity of illness (SOI) of the patient. We want to know which conditions were present on admission (POA) and how the patient’s care progresses through to discharge. It is all this documentation that helps to determine the final payment, the determination of the final DRG, and it is going to determine what the hospital and physician profiles on a variety of measures.
Certainly, medical necessity is driven by what is documented, and when we have clarity and consistency in documentation, CDI programs can impact length of stay concerns, also. If the CDI program includes all these concerns, and we have clear documentation for all of the conditions that were treated while the patient was in the hospital, then you’re going to be compliant, and it’s going to help you avoid being audited by not only by RAC, but whatever other auditing body may want to review any of your records.
When you look at what truly is the line of severity, or the line of SOI as I like to call it, you’ll see that what we’re really trying to do through documentation improvement is ensure that all of the conditions being treated are clearly and appropriately identified. In other words, we all know that there’s a little bit of a discrepancy in the language and wording used in the medical world as opposed to the language used on the coding side. It is (was) this discrepancy that was kind of why we all started having CDI programs in the first place.
You don’t want to over-document conditions that aren’t really being treated. You don’t want to have the facility reimbursed for care that wasn’t part of the patient’s clinical picture. Conversely, you don’t want to have situations arise where, because of the inaccuracy or lack of specific documentation, you lose the opportunity to get the appropriate codes, get the correct patient profile, and get the right reimbursement.
Take that just a little step further. Appropriate documentation of the SOI of the patient is going to support quality and core measures scores as well. Those are the pieces of the documentation that then drives profiling and they are the pieces of documentation that impact where the case mix index goes, the average of all those relative weights of all those DRGs required to support the appropriate length of stay, and that too gets reflected in hospital and physician profiles.
As we look to the future of healthcare and how facilities and physicians are reimbursed, and what’s happening with their payment structure, it’s becoming more and more clear that there’s going to be some comparison between what’s happening in the hospital and the documentation in the hospital, and what the physician might be billing for that visit.
We want to make sure that the documentation those are as accurate as possible to compliantly get what we deserve and support where we are billing.
Editor’s Note: This post was excerpted from the audio conference “Clinical Documentation Improvement: Strengthen your program and protect against denials,” presented on Thursday, January 27.
