Teaching physicians: What’s in it for me (WIIFM)

2. Teaching physicians: What’s in it for me (WIIFM) Margi Brown, RHIA, CCS, CCS-P, CPC

3. Objectives • This “what’s in it for me” session will cover how to get the busiest physician/provider’s attention and keep it with the goal of accurate documentation in mind.

4. Topics of discussion • Establishing the initial contact. • Determining the focus of the presentation(s) and other efforts. • Compiling numbers that impact the physician. • Providing take-away tools. • Sparking interest in their office setting. • Avoiding potholes on the way . • Ensuring ongoing marketing and feedback . • Taking the next steps: Once they are hooked, then what?

5. Determine your bottom line • Hospitals and each physician need the most accurate and specific documentation that translates into correct and compliant coding to reflect the true complexity of care and severity of illness of their patients.

6. Initial steps • Before initiating any contact with providers … • Common goals • Set responsibility • Common goals • Set game plan: • Involvement, staging, calendar

7. Information likely disseminated through insurance company’s website

8. HealthGrades for hospitals And soon MDs as well,provided that Consumer Checkbook wins its appeals

9. Physician public profiling

10. Pay for performance • Definition: Pay for performance (P4P) is a catchphrase for a management tool that establishes incentives for clinicians and institutions (e.g., hospitals) to deliver care that third parties deem is necessary and appropriate to achieve the highest-quality standards and best outcomes. • Current Metrics: • Process-oriented activities • Core Measures, Physician Quality Reporting Initiative (PQRI) • Infrastructure improvements • Principally information technology—CPOE • Patient outcomes • Risk-adjusted mortality

11. P4P goal: Increase value • Defined as outcomes (quality) ÷ Cost • Cost is easy to identify • Outcomes (quality) is not. • The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. • Discernment – What do we measure? • Process functions? (e.g., door-to-wire time) • Death? –Was it expected or unexpected? • Complication rates? –What is preventable and what is not? • Functional outcome? • Patient satisfaction? • Dissemination • How to we communicate our results to our constituency?

12. Goals for both • Physicians: • Encourage physicians to deliver their ethical obligation to practice evidence-based medicine while better allocating resources • More proximal to the medical decision-making • Power of the pen • Power of the knife • Leverage with hospitals is professional relationships or to move their practice to a competitor • Hospitals: • Better develop systems and support • Less proximal but still critical • Leverage with physicians is professional relationships or medical staff credentialing. • Relationships – “Win-Win” between physician and facility • Credentialing–like firing a poor-performing employee

13. Physician reimbursement“Tier and Steer” networks • Three proposed office visit tiers based on cost and “quality of care” by physician: • $15/10% co-payment for tier 1 MD • $30/20% co-payment for tier 2 MD • $45/30% co-payment for tier 3 MD

14. Physician profiling example—Blue Cross of Texas

15. No changes—still measurable … • Where do you fall in the “bell” curve ? or

16. Observation Initial OBS day (3/3): 99218 –99220 Same DOS for admit/disch (3/3): 99234-99236 Disch: 99217 “Extra” days (2/3): 99211-99215 (per CMS) Inpatient Admit, H&P (3/3): 99221-99223 Same DOS for admit/disch (3/3): 99234-99236 Subsequent day (2/3): 99231-99233 Disch: 99238 - < 30 minutes & 99239 - > 30 minutes OBS vs. inpatient—matching?

17. Complexity of medical decision-making • Refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by the following: • Number of possible diagnoses and/or management options • Amount and/or complexity of data • Risk to the patient

18. Complexity of medical decision-making Determined by (1) Number of diagnoses or treatment options, (2) Amount and/or complexity of data reviewed, and (3) Risks of complications and/or morbidity or mortality 1. Number of Diagnoses or Treatment Options B C D A Number Points Results Problem(s) Status Self limited/minor max=2 1 Established problem to examiner … stable/improved 1 Established problem to examiner … WORSENING 2 New problem to examiner w/no additional workup planned max=1 3 New problem to examiner w/additional workup planned 4 TOTAL:

19. Risk of significant complications, morbidity and/or mortality • For E/M: The risk to the patient is based upon the highest level of risk associated with the: • Presenting problem(s) • Diagnostic procedure(s) • Possible management options

20. Explain the data source • For both hospitals and physicians: • Documentation is the bottom line for both, leading to the translation process of narrative diagnoses and procedures to numbers –codes • Comparison of ICD-9-CM and CPT/HCPCS systems • “Severity adjustment” • Mortality and morbidity rates

21. Hospital—IPPS—Inpatient Prospective Payment System methodology One set payment to the hospital is determined by assignment: Of codes for all (documented) diagnoses and procedures To one Major Diagnostic Category (MDC) Then further to one MS-DRG All statistics are based on billed case-mix index (CMI)

22. Who? What? Where? When? How? Why? Why is the patient here today? Daily notes • Each note must: • Support what is coded and billed • Stand alone • Be legible • Show medical necessity

23. Medical necessity and the correct level • "Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. • It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. • The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported.“ • (CMS Claims Processing Manual (Publication 100-04), Chapter 12, Section 30.6.1 - Selection of Level of Evaluation and Management Service).

24. Reimbursement factor—RW • RW (Relative Weight)—Weighted number assignment • Hospital: This number is assigned to each MS-DRG. The assigned weight is intended to reflect relative resource consumption associated with each DRG. • Physician: This number is assigned to each CPT/HCPCS code.

25. CMI and the provider • Low CMI = low “severity” low “quality”? • High CMI = high expected cost & LOS? • My patient’s are sicker. • Measurement of high cost with low CMI = loss for patient, insurance company, hospital, and physician? (contracts?) • Credentialing, pay for performance – how does the physician rate? • Complete picture of quality, core measures, resource consumption, LOS, cost, compliance, audit risk, and much more.

26. Analyze the stats • Dr. 1 1.03 • Dr. 2 0.96 • Dr. 3 1.11 • Dr. 4 1.07 • Dr. 5 1.03 • Dr. 6 1.05 • Dr. 7 1.10 • Dr. 8 1.17 • Dr. 9 1.05 • Dr. 10 1.04 • Dr. 11 1.03 • Dr. 12 0.95 • Range = 0.95 – 1.17 • If Medicare Reimbursement for case mix of 1.0 = $4500 per patient • Low = 4275 • High = 5265 • most likely to risk RAC? • best mortality adjusted data? • discharge patients with more symptom diagnosis? (chest pain, syncope, AMS…)

27. Doctor 1 1.28 Doctor 2 0.81 Doctor 3 1.15 Doctor 4 1.42 Doctor 5 1.09 Pulmonary /Critical Care Range: 0.81 – 1.42 If Medicare reimbursement for case mix of 1.0 = $4500 per patient Low = 3645 High = 6390 Have illegible handwriting? Show the most resistance to coding queries? Will have the highest mortality (risk adjusted)? Are most likely to have his/her data published in the newspaper Analyze the stats

28. PD—Principal diagnosis • Coding guideline for inpatient hospital cases • Principal diagnosis • "that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.“

29. Acute Could not be treated as outpatient Meets admit criteria Acutely treated Aggressively Managed Principal Diagnosis The principal and the why’s

30. Secondary diagnoses and other • Comorbidity: • A pre-existing condition that affects the treatment received or the length of stay • Complication: • A condition that arises during the hospital stay that affects the treatment received or the length of stay • MCC or CC • Data integrity • Medical necessity • Where do you draw the line? • Discharge status • When does it count?

31. Example of vagueness • Provide real-life samples • Now ask: What was their billing for the physician? • Critical care? • Level: 9923_: 1,2, or 3? • Medical necessity • Link back to their bell curve, their stats, and compare to the hospital stats

32. POA defined • POA—Present on Admission purpose • To differentiate between conditions present on admission and conditions that developed during an inpatient admission. • The focus is to assess the timing of when the condition presented. • Pre-existing or hospital-acquired?

33. Read more @ Share your Hospital Infection Story Don't let a hospital kill you - CNN.com Story Highlights. CDC: 99,000 people die annually from hospital-acquired infections ... Watch more on preventing hospital infections " ... www.cnn.com ABC News: Deadly Hospital Infections Occurring More ... the hospital even identified the type of infection …. abcnews.go.com Stop Hospital Infections LEARN MORE. SHARE YOUR STORY. DISCUSS. BLOG. Our Dedicated Activists ... legislators the perspective of living with and surviving a hospital infection. ... www.stophospitalinfections.org

34. HAC –Yes or no, and why?

35. Liability implications • Were prevention guidelines followed? • Public reporting of infections, hospital-acquired conditions (HACs). • MD-specific data on HACs. • Increase in lawsuits against hospitals/MDs. • Some HACs or infections are expected. • How can hospitals/MDs defend against HACs?

36. Provider defined for POA • “Medical record documentation from any provider (a physician or any qualified healthcare practitioner who is legally accountable for establishing the patient’s diagnosis) involved in the patient’s care and treatment may be used to support the determination of whether a condition was present on admission or not; and the importance of consistent, complete documentation in the medical record cannot be overemphasized” MLN Matters number: MM5499 Related Change Request Number: 5499, 091107 update and Transmittal #289 071707 update

37. Joint effort • “Finally, you should keep in mind that achieving complete and accurate documentation, code assignment, and reporting of diagnoses and procedures requires a joint effort between the healthcare provider and the coder.” MLN Matters number: MM5499 Related Change Request Number: 5499, 091107 update and Transmittal #289 071707 update

38. National top 10 list

39. What do you mean? • Low H/H • Insufficiency/distress • Infiltrate • Hypotension • Symptom, sign, or ¯ • AMS, weakness, chest pain, … • Contradiction (attending vs. consultant) or terms • Lab/radiology/path finding • Acuity • Anemia … due to- • Failure • Pneumonia or CHF • Shock. ? Type, ? other • Due to, Link, Diagnosis/disease • Clear and concise • Clinical significance • Acute, chronic, acute on chronic

40. Provide examples of inference • “Clinically” or “reasonably” vs. actual documentation • Meaning? Interpretations differ? • CMS to set the policy: • Determinations are “inconsistent” • Error rate is “compromised” • “lack of understanding documentation requirements” • Disservice by “under-documenting” • Continuity of pt care, severity, LOS, resources • Patient – prevent from obtaining necessary services? • Increased and inaccurate out of pocket costs?

41. Call it what it is • Obesity • Morbid obesity • Delirium • Sepsis vs. urosepsis • (VAP)—“Ventilator associated pneumonia” specifically documented by the physician • Hypoxia • “Acute” exacerbation …

42. Heart failure weighted

43. Did the decubitus exist POA? • Where was patient admitted from? • Is there a skin exam in the ER or by the admitting physician? • Check the H&P. • Skin breakdown, redness, when was this initially noted and by whom? • Is the diagnosis of “ulcer”, the type, the stage, and POA clearly documented? • Physician query is required. Before skin breakdown into an ulcer – redness Superficial well-defined decubitus ulcer

44. Wound progression • “It is possible for a wound to "go from a stage I wound to a stage III or IV" without the intermittent stage[s] being observed. • All wound stages were present just not obvious, hence the need to treat all wounds as serious with the potential of rapidly worsening.” www.expertlaw.com/library/malpractice/decubitus_ulcers.html Stage 4 decubitus ulcer

45. http://www.merck.com/mmpe/sec01/ch002/ch002b.html

46. Symptoms—Diagnoses? • Different diagnosis potential, different codes, and different MS-DRGs, with different reimbursement: • Seizure–100-101 • Syncope–312 • Near syncope • Orthostasis • Orthostatic hypotension–312 • Vertigo, dizziness – (dysequilibrium)–149 • Weakness–947-948 • Altered mental status–947–948 • Decreased level of consciousness • Alteration of consciousness—081 • Dementia—884

47. SOB Distress AMS Chest Pain Insufficiency Clarify Underlying Cause Mass Hypoxia Weakness Underlying cause due to more specific diagnosis?

48. Encephalopathy choices—Many types, many codes, many MS-DRGs, and RW difference Alcoholic 291.2 MS-DRG 894-896 (FY08: 0.3571–1.0419, FY9: 0.3878-1.327) Chronic cerebral ischemic 437.1 – MS-DRG 069 (FY08: 0.7339, FY09: 0.7157) Due to dialysis 294.8-MSDRG 884 (FY08: 0.8431, FY09: 0.8992) Hepatic 572.2 – MS-DRG 441-443 (FY08: 1.3973 – 0.9079, FY09: 106639-0.6982) Hypertensive 437.2 – MS-DRG 077-079 (FY08: 1.4611-0.9839, FY09: 106233-0.7398) Hypoglycemic 251.2 or – Wernicke’s 265.1 MS-DRG 640-641 (FY08: 0.9793-0.7248, FY09: 1.1138-0.6820) Metabolic 348.31 or Unspecified 348.30 – MS-DRG 070-072 (FY08: 1.6212-0.9586, FY09: 1.8246-0.7650) Post-traumatic 310.2 – MS-DRG 101-102 (FY08: 0.8258-0.8710, FY09: 0.7617-0.9584) Toxic and Toxic-metabolic 349.82 – MS-DRG 091-093 (FY08: 1.3242 – 0.7710, FY09: 1.5747-0.6777)

49. Acute ischemic stroke with use of thrombolytic agent Intracranial hemorrhage or infarction Nonspecific CVA and precerebral occlusion without infarction 061: w MCC – FY08-2.5541 FY09-2.8717 064: w MCC FY08-1.5470 FY09-1.8450 067: w MCC FY08-1.2194 FY09-1.3873 062: w CC FY08-2.0886 FY09-1.9537 065: w CC FY08-1.1901 FY09-1.1760 068: w/o MCC FY08-0.9131 FY09-0.8457 63: w/o CC/MCC FY08-1.8642 FY09-1.5143 066: w/o CC/MCC FY08-1.0303 FY09-0.8439 TIA – 069 FY08-0.7339 FY09-0.7157 Stroke MS-DRGs and weights

50. 1991 ACCP/SCCM consensus conference definitions Sepsis = Infection + SIRS* Severe Sepsis = Infection + SIRS + Organ Dysfunction Septic Shock = Infection + SIRS + Organ Dysfunction + Hypotension Sepsis clinical definitions *Note: SIRS= Systemic Inflammatory Response Syndrome