By: Cheryl Ericson, RN, MS, CCDS, CDIP

Documenting a diagnosis in the health record extends beyond its impact on reimbursement and quality-of-care measures. It is also critical to patient safety.

As a clinical documentation integrity (CD) I professional with a nursing background, since I’m no longer at the beside, I often feel disconnected from the human aspect of my work. I know I am doing important work to ensure healthcare data is accurate, but am I really impacting the lives of patients?

It turns out, I am, but maybe not how you would expect. One of the more challenging aspects of our work as CDI professionals is physician engagement, which is why connecting our work to the patient level is so important. Many providers don’t want to hear about how their documentation impacts hospital reimbursement and it difficult to demonstrate a direct impact between their documentation and quality performance measures except when a patient dies, which is a sensitive subject. That is why I’m so excited to share with you an Agency for Healthcare Research and Quality (AHRQ) call to action to improve diagnosing patients.

The importance of documenting a diagnosis in the health record extends beyond its impact on reimbursement and quality-of-care measures. It is also critical to patient safety. AHRQ states, “The diagnosis explains a patient’s health problem, informs every subsequent healthcare decision, and is developed through the iterative process of information gathering, information integration, and information interpretation.” Good patient outcomes require the right diagnosis.

According to AHRQ, diagnostic errors are an emerging safety concern that can “involve up to 12 million patients annually in U.S. ambulatory settings alone and contribute to death for up to 80,000 patients in U.S. hospitals annually.” It involves missed opportunities related to various aspects of the diagnostic process that includes “recognition of key signs, symptoms, and test results.” Diagnostic errors contribute to diagnostic safety events, which may or may not result in patient harm. These are defined by AHRQ as the following:

There were one or more missed opportunities to pursue or identify an accurate and timely diagnosis (or other explanation) of the patient’s health problems based on the information that existed at the time.

An accurate diagnosis (or other explanation) of the patient’s health problems was available, but it was not communicated to the patient (includes patient’s representative or family as applicable).”

Although there are many factors that contribute to diagnostic errors, the primary objective is to identify a patient’s illness quickly and accurately, a goal shared by CDI professionals. One of the primary contributors to diagnostic errors is the current state of diagnosis education. “Diagnosis begins with obtaining an appropriate history from the patient and performing a hypothesis-driven physical examination, but evidence suggests that even these most basic elements are often deficient. Diagnosis then depends on clinical reasoning to apply the clinician’s depth of knowledge in an effort to make sense of the patient findings in the appropriate context.

Clinical reasoning is challenging and represents the dominant issue in diagnostic error, as repeated studies have shown.” Many medical schools do not explicitly address clinical reasoning through curriculum dedicated to this topic. However, medical schools are not alone in this deficit, AHRQ found it also extends to nursing, pharmacy, and other fields.

CDI professionals can be part of the solution as organizations develop processes to reduce diagnostic errors. The work of CDI already includes reviewing health records for diagnoses that explain abnormal diagnostic indicators. Often CDI professionals are reluctant to query a provider immediately when documentation gaps are identified, instead preferring to give the provider the opportunity to interpret the results and arrive at a conclusion before querying, which could delay the query process and subsequent documentation of an associated diagnosis by days, but is that the best strategy?

I’ll freely admit that not all diagnosis will carry the same weight, but it is clear from the AHRQ research that CDI professionals should be more proactive in supporting patient safety related to diagnostic errors by bringing documentation gaps to the healthcare team sooner than later.

Perhaps this is the “What’s in it for me?” that CDI professionals needed all along to engage providers because accurately documenting diagnoses is a patient safety issue.

By: Cheryl Ericson, RN, MS, CCDS, CDIP

HACRP is designed to reduce rates of healthcare-associated infections

Most clinical documentation improvement (CDI) professionals are aware of hospital-acquired conditions (HACs). In fact, reviewing a record and looking for potential HACs may be part of their standard workflow. What many who perform these reviews or manage the CDI process may not realize is that the concept of HACs, and along with it a focus on patient safety, was expanded with the Hospital-Acquired Conditions Reduction Program (HACRP). Yes, HACs are still around, but their potential financial impact at an individual healthcare organizational level is far less than a penalty incurred under the HACRP.

HACs were one of the Centers for Medicare & Medicaid Services’ (CMS’s) first ventures into aligning payment and quality of care. They were developed as part of the Deficit Reduction Act (DRA) of 2005, which required the Secretary of the U.S. Department of Health and Human Services (HHS) (which oversees CMS) to “identify conditions that are: a) high-cost, high-volume, or both; b) result in the assignment of a case to a DRG that has a higher payment when present as a secondary diagnosis; and c) could reasonably have been prevented through the application of evidence-based guidelines.” However, HACs were not implemented until the Inpatient Prospective Payment System (IPPS) Final Rule for the 2009 fiscal year (FY). Part of the reason for this delay was that implementation of HACs was dependent upon implementation of the present-on-admission indicator (POA). Prior to implementation of the POA indicator, CMS did not have an objective way of differentiating co-morbidities (e.g., those conditions that existed prior to the admission) from complications (those conditions that arose during the admission). In this context, complications do not imply wrongdoing on the part of the healthcare organization; it is merely the terminology CMS used.

There were initially 10 categories of HACs, but it subsequently grew to 14 categories, and has remained at 14 since the IPPS for FY 2013 was introduced. Basically, few changes have occurred with HACs, except for the conversion to the ICD-10-CM/PCS code set (which occurred in FY 2016), since the FY 2013 update. The current categories of HACs are:

• Foreign Object Retained After Surgery
• Air Embolism
• Blood Incompatibility
• Stage III and IV Pressure Ulcers
• Falls and Trauma (e.g., Fractures, Dislocations, Intracranial Injuries, Crushing Injuries, Burn, Other Injuries)
• Manifestations of Poor Glycemic Control (e.g., Diabetic Ketoacidosis, Nonketotic Hyperosmolar Coma, Hypoglycemic Coma, Secondary Diabetes with Ketoacidosis, Secondary Diabetes with Hyperosmolarity)
• Catheter-Associated Urinary Tract Infection (UTI)
• Vascular Catheter-Associated Infection
• Surgical Site Infection, Mediastinitis, Following Coronary Artery Bypass Graft (CABG):
• Surgical Site Infection Following Bariatric Surgery for Obesity
  • Laparoscopic Gastric Bypass
  • Gastroenterostomy
  • Laparoscopic Gastric Restrictive Surgery
• Surgical Site Infection Following Certain Orthopedic Procedures
  • Spine
  • Neck
  • Shoulder
  • Elbow
• Surgical Site Infection Following Cardiac Implantable Electronic Device (CIED)
• Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) Following Certain Orthopedic Procedures:
  • Total Knee Replacement
  • Hip Replacement
• Iatrogenic Pneumothorax with Venous Catheterization

You can find a listing of HACs for FY 2022 and the associated ICD-10-CM/PCS codes online at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/icd10_hacs.

So, what is the possible impact of HACs, and why do some CDI departments include identification of potential HACs in their review process? According to a 2020 FAQ published by CMS, “hospitals no longer receive additional payment for cases in which one of the identified HACs occurred but was not POA. Instead, the case is paid as though the HAC was not present. This payment provision applies only to secondary diagnosis codes, given that the identified HACs are designated as a complication or comorbidity (CC) or a major complication or comorbidity (MCC) when reported as a secondary diagnosis. Payments will be adjusted only if no other CC/MCC conditions are reported on the claim.” In other words, if a HAC is identified on the claim, that condition can no longer impact the MS-DRG assignment as a CC or MCC, which could negatively impact reimbursement for that particular claim if there is not another CC or MCC to replace the impact of the HAC. The impact is limited to one claim, and only if it was the only secondary diagnosis that impacted the MS-DRG assignment.

Due to efforts by CDI departments to have multiple CCs and MCCs on every claim, when possible, HACs have little if any financial impact on most healthcare organizations. CMS does, however, publicly report HACs for Foreign Object Retained After Surgery; Blood Incompatibility; Air Embolism; and Falls and Trauma because these measures are not covered by any other CMS quality program. However, CMS does not risk-adjust HAC measures based on patient case mix, because these are considered by CMS “to be serious, reportable events that should not occur, regardless of the patient’s condition.” All other HACs have been “absorbed” into other CMS quality measures, such as CMS PSI 90, which is included in the HACRP. Although they both include the concept of hospital-acquired conditions, the HAC (POA) program and HACRP are two distinctly different quality programs.

According to CMS, “the Hospital-Acquired Condition (HAC) Reduction Program is a Medicare value-based purchasing program that reduces payments to hospitals based on how they perform on measures of hospital-acquired conditions.” It was established by the Patient Protection and Affordable Care Act of 2010 and implemented with the IPPS for FY 2015. The HACRP is designed to encourage use of best practices by healthcare organizations to reduce rates of healthcare-associated infections (HAIs) and improve patient safety. Unlike the HAC program, which only impacts CMS reimbursement on a per-claim basis, the HACRP “adjusts payments to hospitals that rank in the worst-performing quartile (above the 75th percentile) … with respect to measures of hospital-acquired conditions. On an annual basis, CMS evaluates overall hospital performance by calculating a Total HAC Score for each hospital as the equally weighted average of their scores on measures included in the program. Hospitals with a Total HAC Score greater than the 75th percentile of all Total HAC Scores … receive a payment reduction of 1 percent on overall Medicare fee-for-service (FFS) payments.”

Additionally, data collected for the HACRP is publicly reported. The HACRP is updated annually as part of the IPPS. Currently, The HAC Reduction Program includes the following six quality measures:

• One claims-based composite measure of patient safety:
  • CMS Patient Safety and Adverse Events Composite (CMS PSI 90)
• Five chart-abstracted measures of HAIs submitted to the Centers for Disease Control and Prevention’s (CDC’s) National Healthcare Safety Network:
  • Central Line-Associated Bloodstream Infection (CLABSI)
  • Catheter-Associated Urinary Tract Infection (CAUTI)
  • Surgical Site Infection (SSI) for abdominal hysterectomy and colon procedures
  • Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia
  • Clostridium difficile Infection (CDI)

It is important to note that data related to HAIs is not based on claims data; this data is routinely collected as surveillance data by infection control teams and submitted directly to the CDC. Another key difference between the HAC program and HACRP is that the HAC program occurs in real time. The penalty is assessed when the claim is submitted because it is built into claims payment logic. Conversely, data used to determine payment penalties for the HACRP is collected several years prior to the application of the penalty. The FY 2022 HACRP performance period for CMS PSI 90 is based on data collected from July 1, 2018 to Dec. 31, 2019, and the data for the HIA measures was collected from the 2019 calendar year (CY). If organizations only improve patient safety once they receive a HACRP penalty, it could take several years before they are able to right the ship to avoid additional penalties. The good news about HACRP from the CDI perspective is that monitoring performance aligns with efforts to monitor patient safety indicators (PSIs) due to the composite measure of CMS PSI 90, so many CDI departments already have processes in place that could be expanded to include the HACRP.

By: Cheryl Ericson, RN, MS, CCDS, CDIP

“Upcoding” remains a common mechanism of improper payments.

“Healthcare compliance is the process of following rules, regulations and laws that relate to healthcare practices,” according to the PowerDMS Policy Learning Center. Although all healthcare organizations have a compliance department, how the clinical documentation integrity (CDI) department interacts with compliance and supports practices compliant with Centers for Medicare & Medicaid Services (CMS) regulations varies across health systems. The purpose of a compliance program is to prevent, detect, and correct non-compliance to avoid fraud, waste, and abuse.

According to the U.S. Department of Health and Human Services (HHS), some healthcare entities pose a heightened risk to the financial security of Medicare due to the volume of improper payments they incur. Healthcare organizations have a duty to submit proper claims to CMS; however, “upcoding” remains a common mechanism of improper payments. Because compliance is the responsibility of everyone employed by the health system, CDI leadership should be actively engaged in monitoring CMS claims data for potential overpayments that could represent simple errors or process issues resulting in institutional non-compliance. In particular, CDI departments should be gatekeepers meant to avoid “billing for services at a level or complexity higher than services actually provided or documented in the medical record,” according to CMS.

An overpayment is defined by Medicare as one that “exceeds regulation and statute properly payable amounts.” Medicare overpayments can occur due to “incorrect coding and/or insufficient documentation,” both of which should be monitored by CDI and coding leadership. Healthcare entities have 60 days from overpayment identification to report and return a self-identified overpayment to Medicare. Reporting of an overpayment should include a written explanation for the overpayment, e.g., coding error, failure to follow organizational billing practices, etc. The concept of “identification” is broadly applied, as the rule states that this means when a person has or “should have, through the exercise of reasonable diligence” determined an overpayment.

Misusing codes on a claim, such as upcoding (when a provider assigns an inaccurate billing code to a medical procedure or treatment to increase reimbursement) and coding errors are examples of Medicare abuse if the incorrect coding or billing practices are not widespread practices, in which case it could be an example of fraud. CDI and coding professionals are both subject to the federal civil False Claims Act (FCA):

“The civil FCA imposes civil liability on any person who knowingly submits, or causes the submission of, a false or fraudulent claim to the Federal Government. The terms ‘knowing’ and ‘knowingly’ mean a person has actual knowledge of the information or acts in deliberate ignorance or reckless disregard of the truth or falsity of the information related to the claim. No specific intent to defraud is required to violate the civil FCA.”

CMS has a variety of tools to monitor inaccurate payments, including the Comprehensive Error Rate Testing (CERT) Program, Medicare Administrative Contractors (MACs), and the Recovery Auditors. According to CMS, the CERT program reviews a statistically valid stratified random sample of Medicare fee-for-service (FFS) claims to determine if they were paid properly under Medicare coverage, coding, and payment rules. CERT findings create the framework for MAC audits and those performed by Recovery Auditors. While CERT leverages a random sample of claims, the Program for Evaluating Payment Patterns Electronic Report (PEPPER) data provides hospital-specific Medicare claims data. Target areas included in PEPPER were identified by Recovery Auditors and MACs, and are updated periodically.

“PEPPER is an electronic report that provides provider-specific Medicare data statistics for discharges/services vulnerable to improper payments. PEPPER cannot be used to identify the presence of payment errors, but it can be used as a guide for auditing and monitoring efforts to help providers identify and prevent payment errors.”

If you manage a CDI or coding department, you should be reviewing your PEPPER data on a quarterly basis; however, the national download rate is currently at 62 percent. Failure to monitor Medicare claims data included in PEPPER can be an example of “deliberate ignorance or reckless disregard,” according to ACDIS, if your organization is an outlier. Although PEPPER data is not specifically distributed to Recovery Auditors or MACs, both of these Medicare contractors have the ability to request charts related to PEPPER target areas, and have sophisticated data mining techniques to identify outliers.

PEPPER target areas are constructed as a ratio. The numerator includes discharges identified from paid Medicare claims per CMS fiscal year (i.e., October to September) quarter that are identified as potentially problematic because they are likely to be miscoded or result in medically unnecessary services. The denominator is the larger reference group that includes the numerator.

For this article, our focus is coding target areas that include:

• Stroke Intracranial Hemorrhage;
• Respiratory Infections;
• Simple Pneumonia;
• Septicemia;
• Unrelated OR Procedures;
• Medical DRGs with CC or MCC;
• Surgical DRGs with CC or MCC;
• Single CC or MCC;
• Severe Malnutrition;
• Excisional Debridement;
• Ventilator Support; and
• Emergency Department Evaluation and Management Visits.

Each hospital’s ratio is compared to other hospitals at the state, MAC jurisdiction, and national levels, resulting in a ranking by volume percentage. PEPPER data uses the high outlier threshold of the 80th percentile and a low outlier threshold of the 20th percentile. If the percentage of paid Medicare claims for the specific target area ranks at the 80th percentile or above, the organization is considered a high outlier for that target area. In other words, the percentage range for a particular target area may be from 20 to 75 percent. The 80th percentile may result in all those hospitals with a target area ratio of 68 percent or higher. The ratios among all hospitals and the 80th percentile cutoff will vary from quarter to quarter.

If you are new to PEPPER and integrating a compliance focus into your CDI or coding practices, a good place to start is the National High Outlier Ranking Report. This page of PEPPER data will have red if your organization is a high outlier in any target area across the most recently reported 12 quarters of data, as well as the total number of times your organization was a high outlier for each target area. If your organization happens to be a high outlier for any coding target area, that does not necessarily mean there is a compliance issue. A best practice is to investigate why your organization is an outlier by sampling claims and reviewing documentation to validate the assigned codes and billing. Ask yourself, does it make sense for your hospital to be among the top 20 percent of all hospitals for that particular target area?

CDI departments are increasingly renaming the “I” from “improvement” to “integrity.” Integrity is defined as “the quality of being honest and having strong moral principles.” Reviewing PEPPER data is a way for CDI and coding managers to identify areas that may be vulnerable to overpayment. If outliers exist, investigate the associated claims to validate the coding and billing. If coding or billing errors occurred, determine the cause(s) of the errors, e.g., human error or process issues, and look for ways to prevent future non-compliant coding and billing practices. Even if your organization is not an outlier or the internal investigation does not reveal the potential for overpayment, CDI and coding leadership should ensure there are safeguards in place to prevent non-compliance, and monitor staff adherence to those processes.

By: Timothy Brundage, MD, CCDS, Medical Director & CEO of Brundage Group

The diagnosis of Healthcare-Associated Pneumonia (HCAP) is clinically out of date and does not effectively code. The diagnosis of HCAP maps to the DRG for simple pneumonia. Simple pneumonia is a diagnosis that can often be treated in the outpatient setting. HCAP clearly does not fit into this DRG grouping, so physicians should update their clinical practice and their documentation.

Here’s why physicians should not document Healthcare-Associated Pneumonia:

• The diagnosis of HCAP is clinically out of date.
• HCAP does not code effectively.
• The use of HCAP as a diagnosis is discouraged by the Infectious Diseases Society of America.
• HCAP is the wrong diagnosis!

Oral antibiotics are extremely effective in treating simple pneumonia. If a patient truly demonstrates medical necessity for inpatient admission to the hospital, the patient likely has either complex pneumonia or sepsis. (Severe) sepsis is now defined as organ dysfunction due to the infectious process, however, physicians often fail to link the pneumonia with the organ dysfunction. Physicians should update their documentation practices.

As an example: a patient is admitted to the hospital with the diagnoses of pneumonia and acute kidney injury (AKI). Effective documentation would link the conditions as “pneumonia causing AKI.” When pneumonia causes the AKI, then the physician should properly diagnose the patient with sepsis or severe sepsis, explicitly linking the organ dysfunction to the infection.

It is exceedingly common for physicians to admit patients to the hospital and treat them with very aggressive antibiotics without adequately documenting a diagnosis to support the reason why “big-gun” antibiotics are necessary. Physicians should allow their choice of antibiotics to drive their documentation.

For example, the following language is clinically appropriate and codes effectively.

• Zosyn, to treat suspected gram negative (pseudomonas) pneumonia
• Vancomycin, to treat suspected MRSA pneumonia
• Zosyn, Clindamycin or Flagyl, to treat suspected aspiration pneumonia

If hospitalists are scrutinized by length of stay metrics, they should understand that expected length of stay (LOS) is calculated using the documented diagnoses. Suspected gram-negative pneumonia creates a longer expected LOS in the hospital than does simple pneumonia.

Our physician-to-physician education creates savvy documenters who understand how to use coding-based language to demonstrate medical necessity and accurately calculate the DRG. With our support, physicians can learn to document effectively to capture the patient’s severity of illness to support the DRG and quality metrics.

Learn more about our services.

The health care industry continues to transition toward a value-based, pay-for-performance system, but there’s still confusion surrounding the different quality and value programs that have been introduced by CMS and how they impact hospitals.

There’s good reason for the confusion. The programs themselves share terminology, leaving you asking yourself, “How does the HAC Deficit Reduction Act differ from the HAC Reduction Program?” Further, quality measures, such as catheter-associated urinary tract infection (CAUTI), span all three programs, yet are calculated differently depending on the program.

It’s critically important for stakeholders to understand the components of each program, as well as how the programs are measured, to implement appropriate action plans to improve quality and prevent CMS penalties. We travel the country clearing up the confusion for hospital organizations, and we’re breaking it down for you here.

This program includes the traditional hospital-acquired conditions (HAC). All of these conditions qualify as either a complication/comorbidity (CC) or a major complication/comorbidity (MCC). However, if the condition develops after admission, it will be excluded from counting as a CC or MCC for reimbursement purposes. In addition, the first four conditions on the list are publicly reported on the Hospital Compare website.

• Foreign object retained after surgery **
• Air embolism **
• Blood incompatibility **
• Falls and trauma **
  • Fractures
  • Dislocations
  • Intracranial injuries
  • Crushing injuries
  • Burn
  • Other injuries
• Stage III and IV pressure ulcers
  • Manifestations of poor glycemic control
  • Diabetic ketoacidosis
  • Nonketotic hyperosmolar coma
  • Hypoglycemic coma
  • Secondary diabetes with ketoacidosis
  • Secondary diabetes with hyperosmolarity
• CAUTI
• Vascular catheter-associated infection
• Surgical site infection, mediastinitis, following coronary artery bypass graft (CABG)
• Surgical site infection following bariatric surgery for obesity
  • Laparoscopic gastric bypass
  • Gastroenterostomy
  • Laparoscopic gastric restrictive surgery
• Surgical site infection following certain orthopedic procedures
  • Spine
  • Neck
  • Shoulder
  • Elbow
• Surgical site infection following cardiac implantable electronic device (CIED)
• Deep vein thrombosis (DVG) / Pulmonary embolism (PE) Following certain orthopedic procedures
  • Total knee replacement
  • Hip replacement
• Iatrogenic pneumothorax with venous catherization

**Publicly reported on Hospital Compare

It’s a startling fact: Under the HAC Reduction Program, hospitals performing in the bottom 25% receive a 1% penalty. The penalty is applied across all Medicare hospitalizations for the year. For a large hospital, the penalty can be over $1 million per year.

The HAC Reduction Program is comprised of patient safety indicator (PSI) 90 (The Patient Safety and Adverse Events Composite), as well as healthcare-associated infections (HAI). PSI 90 was developed by the Agency for Healthcare Research and Quality (AHRQ) and is used to track potential complications and adverse events. Each PSI has unique criteria based on the coded diagnoses in the medical record. Accurate clinical documentation is critical to ensure appropriate clinical care is not inadvertently captured as a complication. PSI 90 is a composite of the following 10 PSIs:

1. PSI 03 Pressure Ulcers
2. PSI 06 Iatrogenic Pneumothorax
3. PSI 08 In Hospital Fall with Hip Fracture
4. PSI 09 Perioperative Hemorrhage or Hematoma
5. PSI 10 Post-op Acute Kidney Injury Requiring Dialysis
6. PSI 11 Post-op Respiratory Failure
7. PSI 12 Peri-op Pulmonary Embolism or Deep Vein Thrombosis
8. PSI 13 Postoperative Sepsis
9. PSI 14 Postoperative Wound Dehiscence
10. PSI 15 Unrecognized Abdominopelvic Accidental Puncture/Laceration

In contrast to PSIs, HAIs are less dependent on clinical documentation and are instead based on abstraction rules developed by the CDC. The following HAIs are abstracted from the hospital chart and reported to the National Healthcare Safety Network (NHSN):

• Central line-associated bloodstream infection (CLABSI)
• Catheter-associated urinary tract infection (CAUTI)
• Surgical site infection (SSI) (colon and hysterectomy)
• Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia
• Clostridium difficile infection

Performance measures under this program give hospitals the potential for up to a 2% penalty or even a bonus, based on the performance of the various measures. There are four domains that are equally weighted: clinical care, person and community engagement, safety, and efficiency and cost reduction.

The same five HAIs reported in the HAC Reduction Program are also included in the Hospital Value-Based Purchasing Program.

• CLABSI
• CAUTI
• SSI (colon and hysterectomy)
• MRSA bacteremia
• Clostridium difficile infection

In addition, PC-01, elective delivery prior to 39 completed weeks gestation, is included for hospitals that offer obstetrics.

This domain is assessed based on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS).Also known as the CAHPS Hospital Survey, it measures patients’ perceptions of their hospital experiences.

This domain is based on Medicare spending per beneficiary. It is risk adjusted and the spending per beneficiary is compared to all hospitals across the nation. The goal of this measure is to reward hospitals that provide comparable care at a lower cost.

The clinical care domain includes six mortality metrics that are publicly reported:

• Acute myocardial infarction (AMI)
• Heart failure (HF)
• Pneumonia
• Chronic obstructive pulmonary disease (COPD)
• Stroke
• CABG

While all six of these mortality metrics are publicly reported, only AMI, HF, and pneumonia are included in the financial calculation of the Hospital Value-Based Purchasing Program.

Medicare’s mortality metric has significant financial and reputation implications. It is important to understand that conditions that develop after admission are not included in the risk adjustment, whereas conditions that are present on admission (POA) are included in risk adjustment. Herein lies the importance of capturing diagnoses as POA when clinically appropriate.

If it’s unclear whether the condition is POA, a query may be warranted to ensure that all diagnoses that contribute to risk adjustment are captured. Additionally, diagnoses that are coded as W—the provider cannot determine if the condition is POA—are counted as POA and thus used in risk adjustment calculations. It’s also important to note that any conditions that are coded in the 12 months prior to admission are included in risk adjustment. This includes prior hospitalizations as well as outpatient encounters.

We share these recommendations with our own clients on how to optimize mortality metrics:

• Ensure diagnoses are captured as POA when appropriate
• Ensure diagnoses capture the appropriate acuity—acute vs. chronic
• Ensure diagnoses are captured to the highest specificity possible

To avoid penalties and thrive under CMS’s HAC Deficit Reduction Act, HAC Reduction Program and Hospital Value-Based Purchasing Program, it’s critical to have a strong CDI department that works collaboratively with the quality department. In addition, thorough clinical documentation combined with accurate coding is essential to ensure correct CC/MCC assignment and appropriate risk adjustment. And lastly, now that you have this summary as a guide, don’t let all the acronyms confuse you!

By: Dr. Timothy Brundage

I just returned from the ACPA National Physician Advisor Conference where I met with physicians who truly care about providing support to their hospitals.

As a key takeaway from the conference, I’d like to encourage Physician Advisors around the country to break down the silos that exist within hospital organizations. Physician advisors should be focused on much more than patient status assignment; they should be looking at the chart from a global perspective to accurately reflect the care provided. This perspective should supersede the utilization review department, the quality department and the CDI department.

The Physician Advisor should examine the chart to ensure that medical necessity is present while also ensuring the documentation supports accurate code assignment and the timeliness of the documentation supports the quality of care provided.

Only diagnoses that are captured Present On Admission (POA = Y or W) are used by Medicare to risk adjust expected mortality. The Physician Advisor should be keenly aware that mortality observed to expected rates are publicly reported. Our hospitals should provide the community with high-quality care that should be reflected as such in the metrics.

The Physician Advisor should be able to take a case review for medical necessity, which contains the documentation of cystitis and acute kidney injury with an acutely elevated Cr of 2, for example, and understand that this may or may not support inpatient status. If the Physician Advisor understands the global care provided to the patient, he or she should immediately work with the attending physician to document more effectively. If the acute kidney injury is explicitly linked to the cystitis, then the clinician should contemplate the diagnosis of severe sepsis based on SOFA.

This will immediately improve documentation that may potentially support inpatient status, support the appropriate DRG assignment to track expected resource consumption and track to the accurate expected mortality.  The utilization management team is supported, the CDI team is supported, and the quality team is supported. Most important, the accurate picture of the patient is reported—and the patient is supported!

The Sepsis-3 JAMA article published in 2016 reports a 10% expected mortality when diagnosing (severe) sepsis using the SOFA criteria.  This patient is sick, even more so than you may believe.

The role of a Physician Advisor is to support the clinician who is caring for the patient. The patient needs high-quality care and the clinician needs to be able to provide the care in the appropriate setting while also demonstrating that he or she is providing high-quality care to the community.

Physician Advisors should be breaking down the silos within hospitals to advocate for global care and global tracking of high-quality care.  They should get involved with the CDI team and the quality team, and make sure they are working with the utilization review team in a coordinated fashion.

It is not uncommon for me to go into a hospital and see the utilization review, CDI and quality teams working completely independently from one another, with very little communication.

The role of the Physician Advisor is to lead the team toward the accurate portrayal and status of the patient, as well as the appropriate tracking of the quality of care that physicians are providing to the community.

And I almost forgot to mention—this will also reduce the risk of denial if audited.

By: Dr. Timothy Brundage

Do you recall the days of being graded on a bell curve? Your grade didn’t necessarily depend on how well you knew the information and performed on a test, but rather on how you compared to your peers.

It occurred to me—after sensing nervousness from hospital administrators who watched their hospitals slip down industry ranking lists, such as U.S. News & World Report Best Hospitals—that these rankings are based on a similar curve.

According to the official announcement, “Prominent changes to the 2018-19 rankings methodology included more emphasis on patient outcomes and patient experience measures.”

You’ll never convince me that the well-respected hospital organizations that slipped down the list are no longer employing capable physicians who provide leading, high-quality care. That’s not it at all! Rather, the hospitals that top the list are focusing on CDI education, and thus documenting more effectively to support quality. The hospitals that rank lower aren’t performing worse than before—they’re just being outperformed on key metrics, such as mortality O/E.

Metrics and subsequent rankings are driven by how well your organization is documenting the entire patient tenure. If there is misalignment across the documentation spectrum, it will appear that you are underperforming, when that’s not the case at all.

Recent data—and personal observance—suggests that many programs within hospitals are designed for local vs. global optimization. For example, documentation teams are focused on optimizing the MS-DRG. Quality teams are focused on HACs (Hospital Acquired Conditions) and PSIs (Patient Safety Indicators). Utilization management teams are focused on documentation to support medical necessity. Each of these teams are effectively addressing the problems within their own space; however, they’re operating in silos. There needs to be a holistic strategy for the organization’s total performance, and each group needs to coordinate its efforts to contribute to that end.

If you’re not getting better, you’re falling behind—and you’re paying for it. There’s more urgency now than ever, as hospitals are facing a 1% penalty to revenue through CMS’s HAC reduction program. We can help! Keep up with the list leaders by keeping up with physician education, and get credit for the high-quality care you provide!